Human Resources

Department

Jefferson County Courthouse Annex 1

**** *****, ***** ***

Jefferson County

Beaumont, TX 77701

409-***-****

Employment

409-***-****, ext. 2391

Fax 409-***-****

Application

Jefferson County Website:

co.jefferson.tx.us

An Equal Opportunity Employer

It is the policy of Jefferson County not to discriminate in employment on the basis of race, religion, color, age, national origin, sex, marital status, veteran status or disability. To request a reasonable accommodation or other assistance, contact the Human Resources Department at 409-***-**** or, for the hearing impaired, through RELAY Texas at 1-800-***-**** or mail your request to the address above.

Name

Date

(Last) (First) (Middle)

Address

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

Telephone

E-mail

(Personal) (Alternate)

Position Applied For

Department

Are you willing to work: Full-time Part-time Temporary Shift work

May we contact your present employer: Yes No

PREVIOUS EMPLOYMENT: List all employment (including military service) for at least the past 10 years. Begin with your present position and work back. Attach additional sheets or resume to provide sufficient qualifying experience data. Please do not write “SEE RESUME”. Be thorough since your answers may determine whether or not you will be considered for a position. The “Reason for Leaving” and “Salary” must be completed. (Attach additional sheets if needed.) Any applicant providing unrequested information may be rejected.

From

To

Job Title

Salary

Employer

Supervisor

Phone No.

Employer Address

Reason for Leaving/Wanting to Leave

Description of Work

From

To

Job Title

Salary

Employer

Supervisor

Phone No.

Employer Address

Reason for Leaving/Wanting to Leave

Description of Work

From

To

Job Title

Salary

Employer

Supervisor

Phone No.

Employer Address

Reason for Leaving/Wanting to Leave

Description of Work

From

To

Job Title

Salary

Employer

Supervisor

Phone No.

Employer Address

Reason for Leaving/Wanting to Leave

Description of Work

Please explain all periods of unemployment exceeding 90 days:

EDUCATION:

Did you graduate from high school? Yes No

If no, last grade completed

GED obtained? Yes No

College-University-Trade

Business-Correspondence School

Name Location

No. Of

Years

Major Area

Of Study

Semester

Hours

Degrees

Granted

(Applicants may be required to provide copies of transcripts and/or diplomas/certificates.)

MILITARY SERVICE:

Branch of Service

List any relevant job-related skills acquired during military service (you

may be required to provide a copy of form DD214).

PERSONAL DATA:

Please list any other names you have used in connection with employment or education

Have you previously worked for Jefferson County? Yes No If so, when?

Department

Position

Supervisor

Are you authorized to work in this country? Yes No (Proof of citizenship or immigration status will be required upon employment)

Can you perform the essential/marginal functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

Have you ever been convicted of or pled guilty or “no contest” to any offense during the past ten years? Yes No

(Conviction may not necessarily disqualify the applicant)

If Yes, List ALL such offenses and state date, name of Court and disposition. (You may omit minor traffic violations for which you paid a fine of $100 or less)

List all counties and states you have resided in within the past 10 years.

List all licenses/certifications/registrations you hold (such as Drivers, electrician, etc.)

Type

Number

Expiration Date

Type

Number

Expiration Date

Specify equipment or office machines you operate:

Are you related to any elected official or person in the employ of the County of Jefferson? Yes No

Name

Where Employed

Relationship

Give the names and addresses of three persons, other than relatives, who have knowledge of your character, experience or ability:

Name

Address

Occupation

Telephone

List any additional experience and training you have had which in your opinion would qualify you for the position you seek:

(Example: apprenticeships, technical skills, foreign languages spoken/written, etc.)

IMPORTANT

It is the responsibility of the applicant to read the following before signing:

APPLICANTS STATEMENT AND AGREEMENT

I certify, where applicable, that I may be granted compensatory time off in lieu of overtime payments.

I certify that the answers given herein are true and complete. I understand that any falsification or willful omission made in my application, resume or interview(s) shall be sufficient cause for dismissal or refusal of employment, whenever discovered. I hereby authorize each former employer, whether given as a reference or not, to answer any questions and furnish any information sought by the County concerning any qualifications for employment. Depending on the department and position applied for, I understand that such investigation may include a full criminal history and FBI records check. I authorize investigation of all statements contained in this application for employment, and I release Jefferson County, its management and appointed and elected officials, and all third parties supplying information to the County from any and all liability, including liability caused by negligence, arising from reference and background checks conducted by or on behalf of the employer about me. Upon my termination, I authorize release of reference information regarding my employment and work record and release Jefferson County from any and all liability resulting from the release of such information. I also understand that this application is subject to the Open Records Act and may be released as a public document.

I understand that my employment is at the discretion of the Commissioners’ Court or elected Department Head concerned, and that Jefferson County is an employment-at-will employer, which means that I may resign at any time and the County may terminate my employment at any time for any or no reason.

I understand that my employment is contingent upon successful completion of a conditional post-employment offer fitness for duty examination which will include a drug screen. This examination will be conducted by health care providers of the County’s selection. I certify that I will fully and truthfully answer any questions asked by the health care providers or staff. I understand that a positive result from the drug screen will eliminate me from consideration from any County job for one year. I also, understand that, once employed, refusal to submit to such exams or a positive result on a drug/alcohol screen will be grounds for disciplinary action, which may include termination. While employed, if my department head requests, I will submit to additional physical examinations by health care providers of the County’s selection for the purpose of determining my fitness for continued employment. If injured during the course of employment, I will promptly report such injury to my supervisor or department head. If medical treatment is necessary or requested, I will submit to treatment or examination by health care providers of the County’s selection.

I understand and agree that if I am applying for a law enforcement or jail position, I will be required to comply with all the requirements of the Texas Commission on Law Enforcement ( TCOLE) or other equivalent agency as required by the State. I further understand that any offer of employment is conditional upon satisfactorily completing all tests, including physical agility, to determine my fitness for this position.

I understand that some departments of the County have an Employee Handbook or policies which describe additional obligations, terms and conditions of employment. I agree to promptly familiarize myself with the terms of such documents and abide thereby, if applicable. I understand and agree that all benefits, programs, rules and policies of the County are subject to exceptions or change at any time, as decided by the County.

I certify that I have carefully read each provision of this application for employment and that I have been given an opportunity to ask questions concerning any provision which I do not fully understand. I understand the acceptance of this application by the employer neither expresses nor implies I will be offered employment.

This application must be physically signed and dated.

(Electronic signatures are unacceptable)

Please indicate your experience/skills/abilities in the following areas:

Typing Speed:

Skills:

Clerical Experience:

No. of Years

Below 40 wpm

10-key by touch

Receptionist

40-49 wpm

Excel

Data Entry

50-59 wpm

Word

Bookkeeping

60-69 wpm

Word Perfect

Filing

Above 70 wpm

Quattro Pro

Purchasing

PowerPoint

Secretarial

Other word processing

Records Management

Other software

Cashier (electronic)

AS/400 Mainframe

Other

Shorthand – speed

Court Reporting

Other:

LABOR/MAINTENANCE/SKILLED CRAFT/EQUIPMENT OPERATION

Please indicate your experience/skills/abilities in the following areas:

Skill Areas:

No. of Years Exp.

Equipment Operated:

No. of years Exp.

Concrete finishing

Water truck

Welding

Chip Spreader

Asphalt work

Backhoe

Surveying

Front End Loader

Setting grades

Bulldozer

Flagging

Trackhoe

Plumbing

Tractor Trailer

Painting

Tractor with mower

Carpentry

Hydraulic excavator

Electrical

Motor grader

HVAC

Dump truck

Auto mechanic

Winch truck

Heavy equip. mechanic

Roller-packer

Sign maintenance

Pneumatic roller

Groundskeeping/landscaping

Gradall

Road maintenance/construction

Sweeper

Other

Sewer/Flush Truck

Other

Jefferson County is an Equal Opportunity Employer. We request that you provide the following information which is used to study recruitment and employment patterns and to provide statistical data to federal compliance agencies. This information will be kept separate from your application and kept confidential and will in no way be used in consideration of your application for employment. Completion of this portion of the form is voluntary. Failure to provide this information will not jeopardize your opportunity for employment with Jefferson County.

Check the most appropriate blank:

Male White (not Hispanic or Latino)

Female American Indian or Alaska Native (not Hispanic or Latino)

Black or African American (not Hispanic or Latino)

Asian (not Hispanic or Latino)

Hispanic or Latino

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)

Two or More Races (not Hispanic or Latino)

“Other”

If “Other”, please specify:

What led you to apply with the County:

Stopped in to check on available jobs Texas Work Force Commission

Referred by a County employee Newspaper or magazine advertisement Checked Jefferson County website

Other (please list)

Contact this candidate