Employment 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.

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Personal Information
What Position?

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Availability: Days Nights Weekends
Company:
Applying to:
First Name:
Middle Name:
Last Name:
Maiden/Alias:
Email Address:
Street Address:
City:
State:
Zip Code:
Home Phone #:
Cell Phone #:
Social Security #:
How did you learn about the position you are applying for?
How did you learn about the position you are applying for?
Which one?
Enter the name of the employee. 
Please specify: 
Please enter the Job ID Code from the Flyer or enter N/A. 
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?
I'm currently employed by the Agency:

What Position?

Employed From - To Dates:

Reason for Leaving:

Do you currently have any relatives employed by the Agency?

Relative Name(s):

Education
High School
Name of School,
City & State
# of Years Completed
Degree/Diploma Certification
Graduated?
Major Course of Study
College
Name of School,
City & State
# of Years Completed
Degree/Diploma Certification
Graduated?
Major Course of Study
Graduate School
Name of School,
City & State
# of Years Completed
Degree/Diploma Certification
Graduated?
Major Course of Study
Other
Name of School,
City & State
# of Years Completed
Degree/Diploma Certification
Graduated?
Major Course of Study
Professional Licenses
Type of License
Agency/State Issued
Date Issued
Expiration Date
License Number
Type of License
Agency/State Issued
Date Issued
Expiration Date
License Number
Type of License
Agency/State Issued
Date Issued
Expiration Date
License Number
Have any of your Professional licenses ever been revoked, suspended, or investigated?
Please explain:
Employment History

AttentionPlease enter up to 3 of your most recent employers even if your employment history is included in your resume. Please start with your most recent employer first.

Most Recent Employer

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:

Second Most Recent Employer

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:

Third Most Recent Employer

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:
Add Employer
Background
Have you ever been dismissed or forced to resign from any employment?
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 Computerized Criminal History (CCH) 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.
1: Company Reference
Reference Name
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.
2: Company Reference
Reference Name
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.
1: Personal Reference
Reference Name
Reference Address
Street Address
City
State
Zip
Reference Phone
Social Security #
I hereby authorize the release of information requested on this form.
2: Personal Reference
Reference Name
Reference Address
Street Address
City
State
Zip
Reference Phone
Social Security #
I hereby authorize the release of information requested on this form.
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:

  1. Chapter 19, Penal Code (criminal homicide)
  2. Chapter 20, Penal Code (kidnapping & unlawful restraint);
  3. Section 21.11, Penal Code (indecency with a child); or Section 21.02, Penal Code (continuous sexual abuse of young child or children)
  4. Section 22.011, Penal Code (sexual assault);
  5. Section 22.02, Penal Code (aggravated assault);
  6. Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
  7. Section 22.041, Penal Code (abandoning or endangering child);
  8. Section 22.08, Penal Code (aiding suicide);
  9. Section 25.031, Penal Code (agreement to abduct from custody);
  10. Section 25.08, Penal Code (sale or purchase of a child);
  11. Section 28.02; Penal Code (arson);
  12. Section 29.02, Penal Code (robbery);
  13. Section 29.03, Penal Code (aggravated robbery);
  14. Section 21.08, Penal Code (indecent exposure);
  15. Section 21.12, Penal Code (improper relationship between educator and student);
  16. Section 21.15, Penal Code (improper photograph or visual recording);
  17. Section 22.05, Penal Code (deadly conduct);
  18. Section 22.021. Penal Code (aggravated sexual assault);
  19. Section 22.07, Penal Code (terroristic threat);
  20. Section 32.53, Penal Code (exploitation of child, elderly individual, or disabled Individual);
  21. Section 33.021, Penal Code (online solicitation of a minor);
  22. Section 34.02, Penal code (money laundering);
  23. Section 35A.02, Penal Code (Medicaid fraud);
  24. Section 36.06, Penal Code (obstruction or retaliation);
  25. 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:

  1. Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
  2. Section 30.02, Penal Code (burglary);
  3. Chapter 31, Penal Code (theft), that is punishable as a felony;
  4. 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;
  5. Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
  6. Section 37.12, Penal Code (false identification as peace officer); or Section 42.01(a)(7), (8), or
  7. 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 ,  ,  acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

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