For State Agency Use Only

THE STATE OF TEXAS Date received

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)

AC (Daytime Phone)

MAILING ADDRESS

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

AC (Work Phone, Optional)

E-MAIL ADDRESS

List any other names used if different from name on this application. List exact title of position or type of work and location f apply:

or which you wish to Job Posting Number Closing Date List the state agency with which you wish to

apply:

Do

rel

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

Full-Time Part-Time Summer Temp/Project Date available for work? Are 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

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

(State), what percent of time?

(Number)

Commercial Driver's License 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 No 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

PERS 283 (0909) Page 1 of 4

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) Yes No Are you a certified interpreter? Yes No Do you speak a language other than English? (If required for this position) Yes If yes, what language(s) do you speak?

No

How fluently? Fair Good Excellent

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

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

Are you currently employed by the State of Texas? Yes No 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 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 veteran? Yes No If yes, list type of discharge status No

Dates of Service (From/To):

Are you a surviving spouse of a veteran who has not remarried? Yes Ifyes, complete dates of service for veteran

No Are you a surviving orphan of a veteran? Yes No 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 from all liability from any damages which may result from furnishing such information to you.

THIS APPLICATION MUST BE SIGNED SIGN HERE: X Signature – Applicant Date PERS 283 (0909) Page 2 of 4

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:

Employer:

Mailing Address:

City & State/ZIP:

Employer’s Telephone No.: AC Immediate Supervisor Name:

Title:

Full-Time

Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

AC Give average #

of hours worked per

week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical

Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you Supervisory/Managerial supervised:

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

Position Title:

E Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

AC Give average #

of hours worked per

week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical

Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you Supervisory/Managerial supervised:

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

PERS 283 (0909) Page 3 of 4

mployer:

Mailing Address:

City & State/ZIP:

Employer’s Telephone No.: AC Immediate Supervisor Name:

Title:

Full-Time

Name:

Last First Middle

Position Title:

Employer:

M

Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

AC Give average #

of hours worked per

week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical

Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you Supervisory/Managerial 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.: AC Immediate Supervisor Name:

Title:

Full-Time

Part-Time

Summer

Temp/Project

Supervisor’s Telephone No.:

AC Give average #

of hours worked per

week if part-time:

Starting Date Leaving Date Current/

Final Salary

Technical

Mo. Day Yr. Mo. Day Yr. Non-Managerial If supervisory, number of employees you Supervisory/Managerial supervised:

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

PERS 283 (0909) Page 4 of 4

ailing Address:

City & State/ZIP:

Employer’s Telephone No.: AC Immediate Supervisor Name:

Title:

Full-Time

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 Mid dle 3 City State ZIP Code 4. Daytime Phone 5. Work Phone 6. Sex

M-Male

F- Female

7. Birth Date 8. Ethnic Origin

Asian/Pac. Am. Ind/

W-White B-Black H-Hispanic P-Islander I-Alaskan O-Other 9. Veteran 10. Surviving Spouse of Veteran

who has not remarried

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

Yes Yes Yes Yes

No No No No

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

06 - Newspaper

07 - College/University Career Day

08 - Human Resource/Personnel Office

09 – Radio

10 - Agency Web Site – Internet

11 - WorkInTexas.com

12 - Other (specify):

X 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 Asia, the Indian 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 peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. AN EQUAL OPPORTUNITY EMPLOYER

. Address

(0909)

Contact this candidate