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)

MAILING ADDRESS

(Street)

E-MAIL ADDRESS

(First)

(City)

(Middle)

(State) (Zip) (Country)

(Daytime Phone)

(Work Phone, Optional)

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 No

Are you willing to work hours other than 8-5? Yes

Are you willing to travel? Yes No

Current Driver's License # (if required for position) No

Date available for work?

If yes, what percent of time?

(State) (Number)

Are you at least 17 years of age? Yes

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

Page 1 of 4

(0923)

What days are you unable to work?

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)

No

Have you ever been employed by the State of Texas? Yes 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 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 veteran? Yes No If yes, list type of discharge Dates of Service (From/To):

No

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

If yes, complete dates of service for veteran

(From/To):

Are you the spouse of a member of the US armed forces or Texas National Guard serving on active duty? Yes No Are you the spouse and primary source of income for a veteran who has a total disability with a rating of at least 70 percent or on individual unemployability? 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

(0923) Page 2 of 4

Full-Time

Temp/Project

Mailing Address:

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.:

Immediate Supervisor Name:

Title:

Supervisor’s Telephone No.:

Part-Time

Summer

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:

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

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:

(0519) Page 3 of 4

Full-Time

Employer:

Position Title: Immediate Supervisor Name:

Part-Time

Mailing Address: Title: Summer

City & State/ZIP: Temp/Project

Employer’s Telephone No.: 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:

Day Yr. Mo. Day Yr. Non-managerial

Supervisory/Managerial

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

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

Title: Summer

City & State/ZIP:

Mailing Address:

Temp/Project

Employer’s Telephone No.: 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:

Day Yr. Mo. Day Yr. Non-managerial

Supervisory/Managerial

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

(0519) Page 4 of 4

For State Agency Use Only:

APPLICANT EEO DATA FORM Applicant Number: 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

W-White B-Black 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

Yes Yes Yes

No No No

12. Spouse of a member of the

US armed forces or Texas

National Guard serving on

13. Spouse and primary source of income for a

veteran who has a total disability with a rating of at least 70 percent or on individual unemployability

14. Former Texas Foster Youth 25 yrs of age

or younger

active duty

Yes No Yes No

Yes

No

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

01 - Other State Employee 06 – Newspaper 11 - WorkInTexas.com Name of Newspaper

02 - Job Fair 12 - Other (specify):

07 - College/University Career Day

03 - Professional Publication

08 - Human Resource/Personnel Office

04 - Recruitment Poster

09 – Radio

05 - Television

10 - Agency Web Site - Internet

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

(0923)

Contact this candidate