For State Agency Use Only
Date received __________
THE STATE OF TEXAS
Time received __________
APPLICATION FOR EMPLOYMENT
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)
(Dayt
ime 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 Te mp/P ro je ct
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 cit
y/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
o
f
School
Name and Location
of School
Dates
Attended
Date
Gr
aduated
Exp
ected
Graduation
Date
Sem/Clock
H
ours
Completed
Ty
pe
of Diploma
or Degree
Major/Mino
r
Fields
of Study
From To
Mo. Yr. Mo. Yr.
Under
g
raduate
Colleges or
Universities
Graduate
Schools
Technical o
r
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)
Y
es
If yes, which language(s)
No
Have you ever been employed by the State of Te
xas?
Yes
No
Are you currently employed by the State of Te
xas?
Yes No
If you have been previously employ
ed 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 18
th
birthday? Yes No
If yes, are you currently 25 years of age or younge
r?
Yes No
MILITAR
Y SERVICE (A copy of a report of separation from the Armed Services may be required.)
Are
ou a veteran? Yes No If
y
es, list t
yp
e of dischar
g
e
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
Tem p/Pr oje ct
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 Telep
hone No.:
Immediate Supervisor Name:
Title:
Supervisor’s Telephone No.:
Part-Time
Summer
Give average #
of hours worked per
week if part-t ime:
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
Tem p/Pr oje ct
Give average #
of hours worked per
week if part-t ime:
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:
Ti
tle: Summer
City & State/ZIP:
Tem p/Pr oje ct
Employer’s Telephone No.:
Supervisor’s
Telephone
No.:
Give average #
of hours worked per
week if part-t ime:
Current/
Final Salary
$
Starting Date Leaving Date
Technical
Mo.
If supervisory, number of employees you
supervised:
Non-managerial
Day Yr. Mo. Day Yr.
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: F
ull-Time
Employer: Part-Time
Title: Summer
City & State/ZIP:
Mailing Address:
Tem p/Pr oje ct
Employer’s Telephone No.:
Supervisor’s
Telephone No.:
Give average #
of hours worked per
week if part-t ime:
Current/
Final Salary
$
Starting Date Leaving Date
Technical
Mo.
If supervisory, number of employees you
supervised:
Non-managerial
Day Yr. Mo. Day Yr.
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 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 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)