Fillable Printable The State of Texas Application for Employment

The State of Texas Application for Employment

Page 1 of 4

(0909)

PRINT IN BLACK I NK OR TYPE. These instructi ons must be followed exactly. Fill out application for m completely. If quest ions are not

applicable, enter " N A." Do not leav e questions blan k. Be s ure t o si gn w hen completed. The State of Texas is an E qual Opportunity

Empl oyer and does not dis cr iminate on the basis of race, col or, national origin, sex, r eligion, age or dis ability in employment or t he

provis ion of ser vic es. You may make c opies of this applic ati on and enter different posi tion titles , but each c opy mu st be si g ned

Resumes wi ll no t be accepted in lieu of applicat ions, unless specificall y stated in the job vacanc y notice. This appl ic ation becomes

public record and is subject to disclosure.

With few except i ons, you have t he right to request and be inform ed about inf orm ati on that the Stat e of Texas collects about you. You are entitled to

recei ve and review the inf orm ation upon request. You also have t he right t o ask the stat e agency to correct any information that is determ ined to be

inc orrec t. (Reference: Government Code, Secti ons 552. 021, 552.023 and 559.004. )

NAME

( )

(Last) (First) (Middle) (Day time Phone)

MAILING ADDRESS ( )

(Street)

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

(Work Phone, Optional)

E-MAIL ADDRESS

Lis t any other nam es used if different from name on this applicati on.

List ex act 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 whi c h 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

Date available f or work?

A re you at least 17 years of age? Yes No

Are you willing to work hours other than 8-5? Yes No What days are you unable to work?

Are you willing to travel? Yes

No If yes, what percent of tim e?

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

Commercial Dri ver's License Yes No

(State) (Number)

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

Have you ever b een convi cted of a felon y or su b jected to deferred ad jud i cation on a felon y charge? Yes No I f your answer is "Yes,"

explain i n c oncise detail on a separate page, giving dates and nature of the offense, name and loc ation of the court, and dis position of t he cas e(s). A

conviction may not disqualify you, but a fals e statement will. Note: Som e state agenci es may require addit i onal i nformat i on related to convicti ons of

misdemeanors.

EDUCATION (NOTE: A ppl icants may be required to provide proof of dipl om a, degree, transc ri pts, licenses, certifi cations, and registrat ions. )

High School G raduat e or GED? Yes No If yes, name and location of high school or GED instit ute:

Type

Da t es A tt en d ed

Date

Expected

Sem/Clock

Type

Major/Minor

Name and Location

From

Graduated

Graduation

Hours

of Diploma

Fields

School

of School

Mo.

Yr.

Mo.

Yr.

Date

Completed

or Degree

of Study

Undergraduate

Coll eg es or

Universities

Graduate

Schools

Technical or

Vocational

Schools

THE STATE OF TEXAS

APPLICAT ION FOR EM PLOYM ENT

For Sta te A gency Use O nly

Date rec ei ved __________

Time received __________

Received by ___________

(0909) Page 2 of 4

AN EQUAL OPPORTU NIT Y EMPLOYER

If a licens e, certificate, or other authorizati on i s required or rel ated to the pos iti on for which you are applying, complete the foll owing:

LICENSE/CERTIFICATION

(P.E., R.N., Att orn e y, C.P. A ., etc.)

Date

issued

Date

expires

Issued by/Location of issuing aut hority

(State or o th er autho rity) (Cit y & State)

Licen se No.

Special Training/Skills/Qualifications: List all job related training or skil ls you poss ess and machines or offic e equipment you can use, such as

cal culators, printing or graphics equipm ent, comput er equipment , t ypes of software and hardware. (At tach additional page, if necessary.)

Approxim ately how many words per mi nute do you type?

Sign Language (If requi red f or this position) Yes No Are you a certifi ed interpret er? Yes No

Do you speak a language other than English? (If requi red for this posi tion) Yes No

If yes, what l anguage(s) do you speak?

How fluent l y? Fair Good Excellent

Do you wri t e i n a l anguage other than English? (If requi red for this posi t i on) Yes No

If yes, whic h l anguage(s)

Have you ever been employed by the State of Texas? Yes No A re you c urrent l y employed by the State of Texas? Yes No

If you have been previously em ployed by the State of Texas, list t he agency/agencies:

FORMER FOSTER YOUTH (Veri f ic at i on may be required.)

W ere you a foster youth under t he Texas Department of Family and Protect i ve Services on the day before your 18

birt hday? Yes No

If yes, are you currentl y 25 years of age or younger? Yes No

MILI TARY SERVICE

(A c opy of a report of separation from the Armed Services may be required.)

Are you a veteran? Yes No I f yes, list type of disc harge

Dates of Service (F rom/To):

Are you a surviving spouse of a veteran who has not remarried? Yes No Are you a surviving orphan of a veteran? Yes No

If yes, complet e dates of service for veteran

PLEASE READ THE FOLLOWING STAT E MENTS CAREFULLY AND INDICATE YOUR

UNDERSTANDING AND ACC E P TANCE BY SIGNING IN THE SPACE PROVIDED

1. I certify that all the informat ion pr ovided by me in connec tion w ith m y application, whether on this document or not, is true and

complete, and I understand that any m is statement, falsification, or om iss ion of information m ay be groun ds f or r efusal to hi re or, if

hired, ter m ination.

2. I unders tand that as a condition of empl oyment, I wi ll be required t o provide legal pro of of authorization to w ork in the U .S.

3. I unders tand that the State of Texas requires all m ales w ho are 18 t hrough 2 5 and required to reg is ter with the S electi ve Servic e, to

present either pr oof of regist ration or exemption from regi st ration upon hire.

4. I unders tand that some state agenci es wi ll check with the Texas Department of Public Safety, the Federal Bureau of Inves tigation or

other organiz ati ons, for any criminal hist ory in accordance w ith applicabl e statutes .

5. I authorize an y of t he pers ons or organi zations refer enced i n this applicat ion to give yo u any and all inform ation concerning my

previous em plo ym ent , education, or any other inf ormation they m ight have, pers onal or otherw is e, wi th r egard to any of t he subjects

covered by this applicat ion, and I releas e all such part ies from al l l iability from any dam ages whi ch may res ult fr om furnishing such

inform ation to you.

THIS APPLICATION MUST BE SIGNED

SIGN HERE:

Signature – Applicant

Date

(0909) Page 3 of 4

EMPLOYMENT HISTORY

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

Summaries of experience should clearly describe your qualifications.

1. Include ALL employment. Begin wi th your current or last position and work back to your first. Emp loy men t histor y shou ld i nclude

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 technic al 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 providi ng the same information in the same format as this application form.

Name

Last

First

Middle

Position T itle:

Employer:

Mailing Address:

City & State/ZIP:

Em pl oyer’s Telephone No.: ( )

Immediate Supervisor Na me:

Title:

Supervisor’s Telephone No.:

( )

Full-Time

Part-Time

Summer

Temp/Project

Give ave rage #

of hou rs work ed per

week if part-time:

Starting Date

Leaving Date

Current/

Technical

Non-Managerial

Supervisory/Managerial

Mo.

Day

Yr.

Mo.

Day

Yr.

Final Salary

If sup ervi sory, number of emp loyee s you

supervised:

Summary of experience including spec i al t raini ng/sk i lls/qual i fications you have us ed i n the perform ance of this j ob:

Specific reason for leaving:

Position T itle:

Employer:

Mailing Address:

City & State/ZIP

Em pl oyer’s Telephone No.: ( )

Immediate Supervisor Na me:

Title:

Supervisor’s Telephone No.:

( )

Full-Time

Part-Time

Summer

Temp/Project

Give ave rage #

of hou rs work ed per

week if part-time:

Starting Date

Leaving Date

Current/

Technical

Non-managerial

Supervisory/Managerial

Mo.

Day

Mo.

Day

Yr.

Final Salary If sup ervi sory, number of employees you

supervised:

Summary of experience including special traini ng/sk i lls/qual i fications you have used in the perform ance of this j ob:

Specific reason for leaving:

(0909) Page 4 of 4

Position T itle:

Employer:

Mailing Address:

City & State/ZIP:

Em pl oyer’s Telephone No.: ( )

Immediate Supervisor Na me:

Title:

Supervisor’s Telephone No.:

( )

Full-Time

Part-Time

Summer

Temp/Project

Give ave rage #

of hou rs work ed per

week if part-time:

Starting Date

Leaving Date

Current/

Technical

Non-managerial

Supervisory/Managerial

Mo.

Day

Yr.

Mo.

Day

Yr.

Final Salary If sup ervi sory, number of employees you

supervised:

Summary of experience including spec i al t raini ng/sk i lls/qual i fications you have used in the performance of this job:

Specific reason for leaving:

Position T itle:

Employer:

Mailing Address:

City & State/ZIP:

Em pl oyer’s Telephone No.: ( )

Immedia te Supervisor Name :

Title:

Supervisor’s Telephone No.:

( )

Full-Time

Part-Time

Summer

Temp/Project

Give ave rage #

of hou rs work ed per

week if part-time:

Starting Date

Leaving Date

Current/

Technical

Non-managerial

Supervisory/Managerial

Mo.

Day

Yr.

Mo.

Day

Yr.

Final Salary

If sup ervi sory, number of emp loyee s you

supervised:

Summary of experience including spec i al t raini ng/sk i lls/ qual i fications you have used in the perform ance of this job:

Specific reason for leaving:

(0909)

APPLICANT EEO DATA FORM

The inform ation requested is optional and is being col lected for the purpose of reporting to Federal and Equal Employment

Opportunity Agencies and will not be considered as part of the appl ication 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 Phon e

( )

6. Sex

M-Male

F- Female

7. Birt h Date

8. Ethnic Origin

Asian/Pac. Am. Ind/

W-White B-Black H-Hispanic P-Islander I-Alaskan O-Other

9. Veteran

Yes

10. Surviving Spouse of Veteran

who has not remarried

Yes

11. Orphan of Veteran

Yes

12. Former Texas Foster Youth

25 yrs of age or younger

Yes

13.

How did you

first

find out about thi s job?

01 - Other State Employee

02 - Job Fair

03 - Professional Publication

04 - Recruitment Post er

05 - Television

06 – Newspaper

Name of Newspaper

07 - College/University Career Day

08 - Human Resource/Personnel Office

09 – Radio

10 - Agency Web Sit e - Internet

11 - WorkInTexas.com

12 - Other (specify):

Signature – Applicant

Date

White (Not of Hispanic origin) – All persons having origins in any of the original peoples of Europe, North Africa, or the Middle

East.

Black (Not of Hispanic origin) – All persons having origins in any of the Black racial groups of Africa.

Hispanic – All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless

of race.

Asian or Pacific Islander – All persons having origins in any of the original peoples of the Far East, Southeast As i a, the Indi an

Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and

Samoa.

American Indian or Alaskan Native – All persons having origins in any of the original peopl es of North America, and who maintai n

cultural identification through tribal affil iation or community recognition.

AN EQUAL OPPORTU NIT Y EMPLOYER

For Sta te Agency Use Only:

Applicant N umbe r : ________________