Texas
Application for Employment
Please Print
Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable
accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
Name ______________________________ Applicant ID# __________
Last First Middle
Address--------------------------------------------
Street City State ZIP Code
Telephone# _,.____,______ Cellular/Other Phone# -"-__,_____ E-mail Address _____________
Position(s) applied for ________________________ Date of application--�--�--
Referral Source (Please check the appropriate category and list the source.)
0 Walk-in-------------------- D School--------------------
□ Employee _________________ □ Job Fair _________________
D Advertisement ----------------- D Staffing Agency ______________
□ Company's Website ______________ D Government
Employment Agency ______________
D Other Internet ----------------- D Other --------------------
If necessary, best time to call you is .................... Will you work overtime if required? ........................... D Yes D No
D Home D Cellular/Other
May we contact you at work? ....................................... D Yes D No If no, please explain: _______________
If yes, work number and best time to call:
Are you able to perform the "essential functions" of the job for which
you are applying (with or without reasonable accommodation)?
If you are under 18 and it is required,
can you furnish a work permit? ................................... D Yes D No This question is not designed to elicit information about an applicant's disability. Please
do not provide information about the existence of a disability, particular accommodation,
or whether accommodation is necessary. These issues may be addressed at a later stage
If no, please explain: _______________ to the extent permitted by law.
Have you submitted an application here before? ...... D Yes D No D Yes D No D Need more information about the
job's "essential functions" to respond
If yes, give date(s) and position(s): _________
Driver's license number required if driving may be required in the
job for which you are applying:
Have you ever been employed here before? ............... D Yes D No State _____
If yes, give dates: From / / To / /
Have you ever been bonded? ....................................... D Yes D No
Is this application a request for reemployment
Answering "yes" to the following question does not constitute an automatic bar to
following an extended military leave of absence employment. Factors such as date of the offense, seriousness and nature of the violation,
from this company? ............................................... D Yes D No rehabilitation and position applied for will be taken into account. NOTE: You are not
obligated to disclose juvenile records that have been sealed.
If yes, additional information may be requested.
Have you ever pleaded "guilty" or "no contest" to
Are you legally eligible for employment or been convicted of a crime?......................................... D Yes D No
in this country? .............................................................. D Yes D No
If yes, please provide date(s) and details:
Date available for work ......................................... / /
What is your desired salary range or hourly rate of pay?
$ __________ Per ________
Type of employment desired: D Full-Time □ Part-Time Have you entered into an agreement with any former employer or
D Educational Co-Op D Seasonal □ Temporary other party (such as a noncompetition agreement) that might, in any
Will you relocate if job requires it? ............................. D Yes D No way, restrict your ability to work for our company? ....... D Yes D No
Will you travel if job requires it? .................................. □ Yes D No If yes, please explain: ______________
If they have been explained to you, are you able to meet the
attendance requirements of the position? ... D N/A D Yes D No
AN EQUAL OPPORTUNITY EMPLOYER Page1
Employment History
Starting with your most recent employer, provide the following information.
Employer Telephone#
...I. . I
Month Year Month Year
Dates employed: to
)
Street address City State I I
Starting job title/final job title
D Hourly D Salary I $ per
$
.. ,.
Commission/Bonus/Other Compensation
Immediate supervisor and title (for most recent position held) May we contact for reference? ,
I
.1■1111
Why did you leave?
Oves □ No 0Later D Hourly D Salary $ per
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Employer Telephone#
I I
Month Year Month Year
Dates employed: to
( )
Street address City State
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Starting job title/final job title
D Hourly D Salary $ per
....,
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference?
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Why did you leave?
Oves □ No 0Later D Hourly D Salary $ per
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
Employer
I
Telephone#
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Month Year Month Year
Dates employed: to
)
Street address City State
I
h111t " I I
Starting job title/final job title
D Hourly D Salary $ per
Commission/Bonus/Other Compensation $
Immediate supervisor and title (for most recent position held) May we contact for reference?
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Why did you leave?
Oves □ No 0Later D Hourly D Salary $ per
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
I
Employer Telephone#
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Month Year Month Year
Dates employed: to
( )
City State "''
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Street address 111111 • I
Starting job title/final job title
D Hourly D Salary $ per
$
..
Commission/Bonus/Other Compensation
Immediate supervisor and title (for most recent position held) May we contact for reference? , ,.
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0Yes 0No D Later D Hourly D Salary $ per
Why did you leave?
E-mail: Commission/Bonus/Other Compensation $
Summarize the type of work performed and job responsibilities.
What did you like most about your position?
What were the things you liked least about the position?
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Employment History (continued)
Explain any gaps in your employment, other than those due to personal illness, injury or disability. _____________
If not addressed on previous page, have you ever been fired or asked to resign from a job? ........................................................ D Yes D No
If yes, please explain:---------------------------------------
Skills and Qualifications
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:
Computer Skills (Check appropriate boxes. Include software titles and years of experience.)
D Word Processing Years: D Internet Years:
D Spreadsheet Years: □ Other Years:
D Presentation Years: □ Other · Years:
DE-mail Years: □ Other Years:
Educational Background
Starting with your most recent school attended, provide the following information.
School (include City and State) Years Completed GPA Major/Minor
Completed Class Rank
D Diploma □ GED
D Degree
D Certification
□ Other
□ Diploma □ GED
□ Degree
□ Certification
□ Other
□ Diploma □ GED
□ Degree
D Certification
□ Other
D Diploma □ GED
D Degree
D Certification
□ Other
References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.
Name Title Relationship Telephone E-mail # of Years
to You Known
Social Security Number
SS#
We will use this information only for employment purposes and make reasonable efforts to safeguard your privacy.
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Related Information
To what job-related organizations (professional, trade, etc.) do you belong?
Exclude memberships that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve
national guard or any other similarly protected status.
Organization Offices Held
List special accomplishments, publications, awards, etc.
Exclude information that would reveal race, color, religion, sex, national origin, genetic information, citizenship, age, mental or physical disabilities, veteran/reserve
national guard or any other similarly protected status.
In your current or a prior job, have you ever written instructions or directions to be followed by employees or customers?
D Yes D No D Not Applicable
If yes, please explain:----------------------------------------
Is there any other job-related information you want us to know about you? _______________________
Applicant Statement
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional),
employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or
job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and
non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant
from consideration for employment on any basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only 30 days. At the conclusion of that time, if! have not heard from the employer and still wish to be considered for
employment, it will be necessary for me to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my
employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract
for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary
and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's president.
I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require
me to complete an I-9 Form in this regard.
This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding
an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, or any
other protected status under applicable federal, state, or local law. This Company likewise does not tolerate harassment based on sex, race, color, religion, national origin,
genetic information, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical
contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or
other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category.
Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer).
The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.
I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further
consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Signatureof Applicant.______________________________ Date----�-
This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal
opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing
COMPL4fRiGHT'" or distributing this product is not liable for any damages arising out of the use or inability to use this product. You are urged to consult an attorney
concerning your particular situation and any specific questions or concerns you may have.
A2179_TX ©2013 EDI Important note: This is approved for use by the purchaser only. This form may not be shared publicly or with third parties.
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