(
)
|
|
|
| II.
Education
|
|
|
|
| High
School:
|
Yes
No
|
| Completed
GED:
|
Yes
No
|
|
|
|
College/University
|
|
|
City and State
|
|
|
Degree Earned or Hours Earned
|
|
|
Major/Minor
|
|
|
Date of Graduation
|
|
|
|
|
College/University
|
|
|
City and State
|
|
|
Degree Earned or Hours Earned
|
|
|
Major/Minor
|
|
|
Date of Graduation
|
|
|
|
|
College/University
|
|
|
City and State
|
|
|
Degree Earned or Hours Earned
|
|
|
Major
|
|
|
Date of Graduation
|
|
|
|
|
| III.
License, Registration Or Certification:
|
|
|
|
|
Type:
|
|
|
License Number:
|
|
|
Granted By:
|
|
|
State Of:
|
|
|
Specialty:
|
|
|
License/Reg Valid From:
|
,
|
|
|
TO
|
|
|
,
|
|
|
|
| IV.
Skills/Abilities:
|
|
|
|
|
Typing/WP Speed:
|
(wpm)
|
|
Short-hand:
|
(wpm)
|
|
Computer Skills:
|
|
|
Secondary Language: (Type)
|
|
|
Fluent Written:
|
Yes
No
|
|
Fluent Verbal:
|
Yes
No
|
|
Other Skills:
|
|
|
|
|
| V.
General Information:
|
|
|
|
|
Position being applied for:
|
|
|
Have You Previously Worked For ACCESS?
|
Yes
No
|
|
Do You Currently Work For ACCESS?
|
Yes
No
|
|
Do You Have Any Relatives Working At This Agency Or Serving
As A Board Of Trustees Member?
|
|
|
Yes
No
|
|
If yes, list names and relationship(s):
|
|
|
|
|
| VI.
Work Preference:
|
|
|
|
|
Earliest Date You Are Available:
|
,
|
|
Salary Range Acceptable $
|
|
|
Will You Consider?
|
FT Employment
PT Employment
TEMP Employment
|
|
|
|
| VII.
Employment History:
|
|
Employment History: LAST
JOB FIRST.
|
|
As a minimum, include all employement for past five years,
with emphasis on last two positions.
If you are currently employed, may we inquire with your
present employer?
|
|
|
Yes
No
|
|
|
|
| Previous
Employer 1
|
|
Employer:
|
|
|
Position Title:
|
|
|
Address:
|
|
|
Date Employed From:
|
(From)
(To)
|
|
Salary:
|
(Beginning)
(Ending)
|
|
Supervisor's Name and Title:
|
|
|
Supervisor's Phone Number:
|
|
|
Reason for Leaving:
|
|
|
Description Of Duties:
|
|
|
|
|
| Previous
Employer 2
|
|
Employer:
|
|
|
Position Title:
|
|
|
Address:
|
|
|
Date Employed From:
|
(From)
(To)
|
|
Salary:
|
(Beginning)
(Ending)
|
|
Supervisor's Name and Title:
|
|
|
Supervisor's Phone Number:
|
|
|
Reason For Leaving:
|
|
|
Description Of Duties:
|
|
|
|
|
| Previous
Employer 3
|
|
Employer:
|
|
|
Position Title:
|
|
|
Address:
|
|
|
Date Employed From:
|
(From)
(To)
|
|
Salary:
|
(Beginning)
(Ending)
|
|
Supervisor's Name and Title:
|
|
|
Supervisor's Phone Number:
|
|
|
Reason For Leaving:
|
|
|
Description Of Duties:
|
|
|
|
|
| Previous
Employer 4
|
|
Employer:
|
|
|
Position Title:
|
|
|
Address:
|
|
|
Date Employed From:
|
(From)
(To)
|
|
Salary:
|
(Beginning)
(Ending)
|
|
Supervisor's Name and Title:
|
|
|
Supervisor's Phone Number:
|
|
|
Reason For Leaving:
|
|
|
Description Of Duties:
|
|
|
|
|
| Previous
Employer 5
|
|
Employer:
|
|
|
Position Title:
|
|
|
Address:
|
|
|
Date Employed From:
|
(From)
(To)
|
|
Salary:
|
(Beginning)
(Ending)
|
|
Supervisor's Name and Title:
|
|
|
Supervisor's Phone Number:
|
|
|
Reason For Leaving:
|
|
|
Description Of Duties:
|
|
|
|
|
| VIII.
Client Abuse/Neglect Affidavit:
|
|
|
By filling in your e-mail address you agree to the
following. I hereby certify that I have not had a confirmed
finding of Abuse or Neglect in any previous employment.
I am aware that my e-mail signature on this application
authorizes this Center to check with any previous employers
directly to confirm that any information I may provide to
you about such employment is accurate.
|
|
|
(Email)
(Date)
|
|
| IX.
General Affidavits:
|
|
AT
A MINIMUM THE CENTER WILL CHECK THE MOST CURRENT THREE BUSINESS
(WORK) REFERENCES. ADDITIONAL REFERENCES MAY BE ATTACHED.
By filling in your e-mail address you agree to
the following.
I hereby authorize ACCESS to investigate my background,
education, and experience. I also authorize former eployers,
former supervisors, and other persons with knowledge of
my background, education or experience to provide any
and all information to the Center. I understand any information
collected during sucj investigations will be confidential
and I will NOT be given access to the information.
I am also aware that ACCESS will (1) conduct a criminal
conviction check through the Department of Public Safety
and that certain convictions can be cause for termination
from employment or contraindications to hire for certain
positions, and (2) that driving records are checked to
determine insurability for center-related driving. An
adverse driving record can cause an employee to be ineligible
for hire.
|
|
Texas Drivers Licenses #:
|
|
|
Expiration Date:
|
,
|
|
Have you ever been convicted of any violation of the law
other than minor traffic violations?
|
|
|
Yes
No
|
| If
yes explain:
|
|
|
|
I understand that a physical examination may be required
for my employment and am willing to undergo such examination
if reuqested, including such drug screening as may be
requested.
I certify that the statements in this application are
true and complete. I understand any false statement may
be sufficient grounds for my application to be rejected
or for discharge if I am already employed by the Center.
I sign and acknowledge this by entering in my E-Mail
address and date.
|
|
|
(Email)
(Date)
|
|
|
|
This application does not constitute an agreement or contract
for employment for any specified period or definite duration.
I understand that no representative of the employer, other
than an other than an authorized officer, has the authority
to make any assurances to the contrary. I further understand
that any such assurances must be in writing and signed by
an authorized officer. I sign and acknowledge this by entering
in my E-Mail address and date.
|
|
|
(Email)
(Date)
|
|
|
|
|
