ESBD_File_353578_texas-application-employment.pdf

(Work Phone, Optional)

Date available for work? Are you at least 17 years of age? Yes No

Commercial Driver's License

No

For State Agency Use Only

Date received __________

THE STATE OF TEXAS

APPLICATION FOR EMPLOYMENT Time received __________

Received by ___________

PRINT IN BLACK INK OR TYPE. These instructions must be followed exactly. Fill out application form completely. If questions are not applicable, enter "NA." Do not leave questions blank. Be sure to sign when completed. The State of Texas is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. You may make copies of this application and enter different position titles, but each copy must be signed.

Resumes will not be accepted in lieu of applications, unless specifically stated in the job vacancy notice. This application becomes public record and is subject to disclosure.

With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023 and 559.004.)

NAME

(Last) (First) (Middle)

MAILING ADDRESS

(Street) (City) (State) (Zip) (Country)

E-MAIL ADDRESS

(Daytime Phone)

List any other names used if different from name on this application.

List exact title of position or type of work and location for which you wish to apply:

Job Posting Number Closing Date

List the state agency with which you wish to apply:

Do you have any relatives working for this agency? If so, list names and relationships:

Full-Time Part-Time Summer Temp/Project

Are you willing to work hours other than 8-5? Yes No

Are you willing to travel? Yes No

Current Driver's License # (if required for position) (State) (Number)

What days are you unable to work?

If yes, what percent of time?

Yes No

Geographic preference. (Be specific to city/area. If no preference, write "statewide.")

Have you ever been convicted of a felony or subjected to deferred adjudication on a felony charge? Yes If your answer is "Yes," explain in concise detail on a separate page, giving dates and nature of the offense, name and location of the court, and disposition of the case(s). A conviction may not disqualify you, but a false statement will. Note: Some state agencies may require additional information related to convictions of misdemeanors.

EDUCATION (NOTE: Applicants may be required to provide proof of diploma, degree, transcripts, licenses, certifications, and registrations.)

High School Graduate or GED? Yes No If yes, name and location of high school or GED institute:

Type of

School Name and Location of School

Dates Attended Date Graduated

Expected Graduation

Date

Sem/Clock Hours

Completed

Type of Diploma or Degree

Major/Minor Fields of Study From To

Mo. Yr. Mo. Yr.

Undergraduate Colleges or Universities

Graduate Schools

Technical or Vocational Schools

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Yes Are you a certified interpreter?

Yes How fluently?

Yes No

Are you currently employed by the State of Texas? No

AN EQUAL OPPORTUNITY EMPLOYER

If a license, certificate, or other authorization is required or related to the position for which you are applying, complete the following:

LICENSE/CERTIFICATION

(P.E., R.N., Attorney, C.P.A., etc.)

Date issued Date expires Issued by/Location of issuing authority (State or other authority) (City & State) License No.

Special Training/Skills/Qualifications: List all job related training or skills you possess and machines or office equipment you can use, such as calculators, printing or graphics equipment, computer equipment, types of software and hardware. (Attach additional page, if necessary.)

Approximately how many words per minute do you type?

Sign Language (If required for this position) No Yes No

Do you speak a language other than English? (If required for this position) If yes, what language(s) do you speak?

No Fair Good Excellent

Do you write in a language other than English? (If required for this position) If yes, which language(s)

Have you ever been employed by the State of Texas? Yes No Yes

If you have been previously employed by the State of Texas, list the agency/agencies:

FORMER FOSTER YOUTH (Verification may be required.)

Were you a foster youth under the Texas Department of Family and Protective Services on the day before your 18th birthday? Yes No If yes, are you currently 25 years of age or younger? Yes No

MILITARY SERVICE (A copy of a report of separation from the Armed Services may be required.)

Are you a v eteran? Yes No

If yes, list type of discharge

Dates of Service (From/To):

Are you a surviving spouse of a veteran who has not remarried? Yes No Are you a surviving orphan of a veteran Yes killed while on active duty?

No

If yes, com plete dates of service for veteran

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR

UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED

1. I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information may be grounds for refusal to hire or, if hired, termination.

2. I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.

3. I understand that the State of Texas requires all males who are 18 through 25 and required to register with the Selective Service, to present either proof of registration or exemption from registration upon hire.

4. I understand that some state agencies will check with the Texas Department of Public Safety, the Federal Bureau of Investigation or other organizations, for any criminal history in accordance with applicable statutes.

5. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties f rom all liability from any damages which may result from furnishing such information to you.

THIS APPLICATION MUST BE SIGNED SIGN HERE:

Signature – Applicant

X Date

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EMPLOYMENT HISTORY

This information will be the official record of your employment history and must accurately reflect all significant duties performed.

Summaries of experience should clearly describe your qualifications.

1. Include ALL employment. Begin with your current or last position and work back to your first. Employment history should include each position held, even those with the same employer.

2. EMPLOYER ADDRESSES MUST BE COMPLETE MAILING ADDRESSES, INCLUDING ZIP CODE.

3. Answer all questions and completely summarize your experience including technical and managerial responsibilities and any special training, skills and qualifications for each position you have held.

If you need additional space to adequately describe your employment history, you may use this employment history sheet or attach a typed employment history providing the same information in the same format as this application form.

Name Last First Middle

Position Title: Immediate Supervisor Name:

Employer:

Mailing Address:

City & State/ZIP:

Employer’s Telephone No.:

Title:

Supervisor’s Telephone No.:

Full-Time Part-Time Summer Temp/Project

Give average # of hours worked per week if part-time:

Starting Date Leaving Date Current/ Final Salary

Technical Non-Managerial Supervisory/Managerial

Mo. Day Yr. Mo. Day Yr. If supervisory, number of employees you supervised:

Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Specific reason for leaving:

Position Title:

Employer:

Mailing Address:

City & State/ZIP Employer’s Telephone No.:

Immediate Supervisor Name:

Title:

Supervisor’s Telephone No.:

Full-Time Part-Time Summer Temp/Project

Give average # of hours worked per week if part-time:

Starting Date Leaving Date Current/ Final Salary

Technical

Supervisory/Managerial Mo. Day Yr

Mo. Day Yr. If supervisory, number of employees you supervised:

Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Non-managerial

Specific reason for leaving:

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Position Title: Immediate Supervisor Name: Full-Time Part-Time Employer:

Title: Summer Mailing Address:

Temp/Project City & State/ZIP:

Supervisor’s Telephone No.:

Give average # of hours worked per week if part-time:

Employer’s Telephone No.:

Current/ Final Salary

Starting Date Leaving Date Technical Mo. Non-managerial If supervisory, number of employees you supervised:

Day Yr. Mo. Day Yr.

Supervisory/Managerial Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Specific reason for leaving:

Immediate Supervisor Name: Full-Time Position Title:

Part-Time Employer:

Title: Summer Mailing Address:

Temp/Project

Employer’s Telephone No.:

City & State/ZIP:

Supervisor’s Telephone No.:

Give average # of hours worked per week if part-time:

Current/ Final Salary

Starting Date Leaving Date Technical Mo. If supervisory, number of employees you supervised:

Non-managerial Day Yr. Mo. Day Yr.

Supervisory/Managerial

Summary of experience including special training/skills/qualifications you have used in the performance of this job:

Specific reason for leaving:

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W-White B-Black

Yes No

Yes No

Yes No

Yes No

06 – Newspaper Name of Newspaper

07 - College/University Career Day

08 - Human Resource/Personnel Office

09 – Radio

10 - Agency Web Site - Internet

11 - WorkInTexas.com

12 - Other (specify):

For State Agency Use Only:

Applicant Number: ________________ APPLICANT EEO DATA FORM

The information requested is optional and is being collected for the purpose of reporting to Federal and Equal Employment Opportunity Agencies and will not be considered as part of the application for employment. It will be separated from the application.

1. Job Posting Number 2. Last Name (Type or Print) First Middle

3. Address City State ZIP Code 4. Daytime Phone 5. Work Phone

6. Sex M-Male F- Female

7. Birth Date 8. Ethnic Origin H-Hispanic A-Asian I-American Indian or Alaskan Native

P-Native Hawaiian or Other Pacific Islander M-Two or More Races

9. Veteran 10. Surviving Spouse of Veteran who has not remarried

11. Orphan of Veteran killed on active duty

12. Former Texas Foster Youth 25 yrs of age or younger

13. How did you first find out about this job?

01 - Other State Employee

02 - Job Fair

03 - Professional Publication

04 - Recruitment Poster

05 - Television

X Signature – Applicant Date

White – a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Black – a person having origins in any of the black racial groups of Africa.

Hispanic – a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaskan Native – a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Native Hawaiian or Other Pacific Islander – a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Two or More Races – a person who primarily identifies with two or more of the above race/ethnicity categories.

AN EQUAL OPPORTUNITY EMPLOYER

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THE STATE OF TEXAS