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Employment Application – Step 1 of 3

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.

Fields in red are required.

Personal Information

Position Desired:		Email Address:
Last Name:	First Name:	Middle:	Maiden/Alias:
Street Address:	City:	State	Zip Code:
County (Texas Residents Only):	Home Phone #: e.g. 222-555-1212	Cell Phone #: e.g. 222-555-1212	Social Security #: e.g. 111-11-1111

How did you learn about the position you are applying for?
Newspaper AdWalk-inInternet postingCurrent EmployeeOther

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

Have you ever been employed by the Agency? YesNo

When? From: (mm/dd/yyyy) To: (mm/dd/yyyy)

What Position?

Reason for Leaving:

Do you currently have any relatives employed by the Agency? YesNo

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Have any of your Professional licenses ever been revoked, suspended, or investigated?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

Attach 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. If additional space is needed, attach a supplementary sheet. Please attach your resume.(Microsoft Word or PDF only)

Employer 1

Employer:	May we contact this employer? NoYes
Address:	Telephone: e.g. 222-555-1212
Employment Dates: From: mm/dd/yyyy To: mm/dd/yyyy
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? NoYes
Address:	Telephone: e.g. 222-555-1212
Employment Dates: From: mm/dd/yyyy To: mm/dd/yyyy
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? NoYes
Address:	Telephone: e.g. 222-555-1212
Employment Dates: From: mm/dd/yyyy To: mm/dd/yyyy
Supervisor's Name:
Starting Salary:	Final Salary:
Last Position Held:
Other Positions Held:
Duties:
Reason For Leaving:

Have you ever been dismissed or forced to resign from any employment? NoYes

If yes, explain:

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

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 and Employee Misconduct Registry 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 and Employee Misconduct Registry will be performed. I have informed the agency of all names, (i.e., maiden, aliases) that I have used in the past. I understand that I may be employed on an emergency basis and that my employment may be temporary pending the results of my Criminal History Check and Employee Misconduct Registry.

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.