DSSW/LifeSpan Job Application

The Agency does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, age, disability, or any other legally protected status. The Agency is an equal opportunity employer.

Personal Information

Position Desired:: Availability: Days Nights Weekends

Company

First Name:

Middle:

Last Name:

Maiden/Alias:

Email Address:

Street Address:

City:

State

Zip Code:

County (Texas Residents Only):: If your county isn't listed, please choose "Other" from the list, and enter the name of your county in the box below.

Other County:

Home Phone #:: ###-###-####

Cell Phone #:: ###-###-####

Social Security #:: ###-##-####

How did you learn about the position you are applying for?: If "Other", please specify:

Have you ever been convicted of a felony or misdemeanor? (Answering yes may not automatically disqualify you): If yes, please explain:

Have you ever been employed by the Agency?: If yes, when?

What Position?

Reason for Leaving:

Do you currently have any relatives employed by the Agency?: Name(s):

Education

	Name of School, City & State	# of Years Completed	Degree/Diploma Certification	Graduated?	Major Course of Study
High School				Yes
College				Yes
Graduate School				Yes
Other				Yes

Professional Licenses

Type of License	Agency/State Issued	Date Issued	Expiration Date	License Number

Have any of your Professional licenses ever been revoked, suspended, or investigated?: If yes, please explain:

Employer 1

Employer:

May we contact this employer?

Address:

Telephone:: ###-###-####

Employment Dates:: From: To:

Supervisor's Name

Starting Salary:

Final Salary:

Last Position Held:

Other Positions Held:

Duties:

Reason For Leaving:

Employer 2

Employer:

May we contact this employer?

Address:

Telephone:: ###-###-####

Employment Dates:: From: To:

Supervisor's Name

Starting Salary:

Final Salary:

Last Position Held:

Other Positions Held:

Duties:

Reason For Leaving:

Employer 3

Employer:

May we contact this employer?

Address:

Telephone:: ###-###-####

Employment Dates:: From: To:

Supervisor's Name

Starting Salary:

Final Salary:

Last Position Held:

Other Positions Held:

Duties:

Reason For Leaving:

Background

Have you ever been dismissed or forced to resign from any employment?: If yes, please explain:

Do you have a current Driver’s License or Identification Card issued from the State of Texas?

Agreement

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also understand and agree that any falsified information or significant omissions may disqualify me from further consideration for employment and, if discovered after I am hired, may result in dismissal.

I also understand that if employment is offered and accepted, such employment is not for any specified term and can be terminated at anytime, with or without cause, by either the Agency or myself. I further understand that this application is not a contract of continued employment, and that my at-will employment status cannot be changed.

In consideration of my being considered for employment, I authorize a thorough investigation of my past employment. I agree to cooperate in such investigation, and release from all liability or responsibility all persons and businesses requesting or supplying such information.

I understand that the Agency requires that a Criminal History Check, Employee Misconduct Registry, and OIG searches will be conducted on persons to whom an offer of employment is made. By signing this application, I acknowledge that I have been informed by the agency that a Criminal History Check, Employee Misconduct Registry, and OIG searches will be performed and EMR/NAR are searched annually. I have also informed the agency of all names, (i.e., maiden, aliases) that I have used in the past.

I understand that the Agency does not subscribe to the Worker’s Compensation plan. I further understand that the Agency does provide an occupational injury plan which may provide certain medical benefits to its employees who are injured on the job.

I have read and agree to the above.

Employment Verification 1 of 2

Reference Name

Company or Personal Reference

Reference Address

Street Address
City
State
Zip

Reference Phone: ###-###-####

Applicant's Name

Social Security #: ###-##-####

Name Used While Employed (if different)

Position Held

Dates Employed: From To

Reason for Leaving

I hereby authorize the release of information requested on this form.
Today's Date

Employment Verification 2 of 2

Reference Name

Company or Personal Reference

Reference Address

Street Address
City
State
Zip

Reference Phone: ###-###-####

Applicant's Name

Social Security #: ###-##-####

Name Used While Employed (if different)

Position Held

Dates Employed: From To

Reason for Leaving

I hereby authorize the release of information requested on this form.
Today's Date

Statement of Employability

Last Name

First Name

Middle Name

Maiden Name

Other Names (aliases, married name, etc.)

Date of Birth

Race/Ethnicity (according to EEOC categories)

Gender

Social Security #: ###-##-####

By execution of this document, I acknowledge that I have been informed by the agency that a criminal history, an EMR/NAR, and State and Federal OIG checks will be performed on my name(s). In addition, if I am hired, the agency will verify EMR/NAR annually, and OIG (State & Federal) monthly. I have informed this agency of all names (i.e., maiden name, aliases) that I have used in the past. I hereby profess that I have not been convicted of any of the following crimes which are a permanent automatic bars to employment by this agency.

A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed below:

Chapter 19, Penal Code (criminal homicide)
Chapter 20, Penal Code (kidnapping & unlawful restraint);
Section 21.11, Penal Code (indecency with a child); or Section 21.02, Penal Code (continuous sexual abuse of young child or children)
Section 22.011, Penal Code (sexual assault);
Section 22.02, Penal Code (aggravated assault);
Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
Section 22.041, Penal Code (abandoning or endangering child);
Section 22.08, Penal Code (aiding suicide);
Section 25.031, Penal Code (agreement to abduct from custody);
Section 25.08, Penal Code (sale or purchase of a child);
Section 28.02; Penal Code (arson);
Section 29.02, Penal Code (robbery);
Section 29.03, Penal Code (aggravated robbery);
Section 21.08, Penal Code (indecent exposure);
Section 21.12, Penal Code (improper relationship between educator and student);
Section 21.15, Penal Code (improper photograph or visual recording);
Section 22.05, Penal Code (deadly conduct);
Section 22.021. Penal Code (aggravated sexual assault);
Section 22.07, Penal Code (terroristic threat);
Section 33.021, Penal Code (online solicitation of a minor);
Section 34.02, Penal code (money laundering);
Section 35A.02, Penal Code (Medicaid fraud);
Section 36.06, Penal Code (obstruction or retaliation);
Section 42.09, Penal Code (cruelty to livestock animals); or Section 42.092, Penal Code (cruelty to non livestock animals);

A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is convicted of:

Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
Section 30.02, Penal Code (burglary);
Chapter 31, Penal Code (theft), that is punishable as a felony;
Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;
Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
Section 37.12, Penal Code (false identification as peace officer); or Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5 (c), Article 42.12, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that this offense(s) may also bar my employment. Also, if I am found to have been reported to the Employee Misconduct Registry and/or OIG Excluded party Lists (State and/ or Federal), this offense(s) may also bar my employment.

I understand that all information obtained by this agency regarding any criminal history and employee misconduct will remain confidential. I have the right to contact DPS, DADS, and/or OIG to request an opportunity to be heard concerning the accuracy of the recorded information that was disclosed to the agency.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

DPS Computerized Criminal History (CCH) Verification

I, , have been notified that a Computerized Criminal History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply.

Because the name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss any criminal history record information obtained using the name and DOB method. Therefore, the agency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

For the fingerprinting process I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System). I have been made aware that in order to complete this process I must make an appointment with L1 Enrollment Services, submit a full and complete set of my fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company, L1 Enrollment Services.

Once this process is completed and the agency receives the data from DPS, the information on my fingerprint criminal history record may be discussed with me.

Upload Resume

In the following spaces give a complete record of your employment including periods of unemployment, if any. Begin with your most recent employment and proceed back to the last 7 years of employment.

Do you want to upload a resume?

Only .pdf, .rtf., .doc, or .docx file formats are allowed.

Employment Application