Job Application

General Information

Name(Required)

First Last

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone(Required)

Receive Text?(Required)

Yes

No

Smart Phone?(Required)

Yes

No

Email(Required)

Internet Access?(Required)

Yes

No

How did you hear about us?(Required)

What day/hours are you available?(Required)

Are you willing to work graveyard?(Required)

Yes

No

If so, what nights?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Select the towns you can work in.(Required)

Other towns available to work in:

Please select all that apply.

Smoker

Non-Smoker

Outgoing

Quiet

Artistic

Sports Fan

Like Pets

Pet Allergy

Education

High School

School Name

Location

Year

Major

Degree/Cert.

College

School Name

Location

Year

Major

Degree/Cert.

CNA Certified?(Required)

Yes

No

Certification #

In addition to your work history, are there any other skills, languages you speak, qualifications, or experience that we should consider?

Emergency Contact Information

Contact Information(Required)

Name

Relationship

Primary Phone

Secondary Phone

Employment History

Please start with the most recent employer.

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Supervisor(Required)

Phone(Required)

Start and End Date(Required)

Wage(Required)

May we contact?(Required)

Yes

No

Reason for Leaving(Required)

Responsibilities(Required)

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Supervisor(Required)

Phone(Required)

Start and End Date(Required)

Wage(Required)

May we contact?(Required)

Yes

No

Reason for Leaving(Required)

Responsibilities(Required)

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Supervisor(Required)

Phone(Required)

Start and End Date(Required)

May we contact?(Required)

Yes

No

Reason for Leaving(Required)

Responsibilities(Required)

References

List three personal references, not related to you, who you have known for more than one year.

Name(Required)

First Last

Phone(Required)

Years Known(Required)

Please enter a number greater than or equal to 1.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(Required)

First Last

Phone(Required)

Years Known(Required)

Please enter a number greater than or equal to 1.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(Required)

First Last

Phone(Required)

Years Known(Required)

Please enter a number greater than or equal to 1.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DPS Computerized Criminal History (CCH) Verification

Employability Consent

Name(Required)

Please print as listed on Social Security card and/or Texas Driver's License.

Additional Alias Names Used(Required)

Including maiden name.

Date of Birth(Required)

Consent(Required)

I acknowledge that I have had no prior convictions of any of the offenses listed below which bar employment.(Required)

(1) an offense under Chapter 19, Penal Code (criminal homicide);
(2) an offense under Chapter 20, Penal Code (kidnapping, unlawful restraint, and smuggling of persons);
(3) an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children), or Section 21.11, Penal Code (indecency with a child);
(4) an offense under Section 22.011, Penal Code (sexual assault);
(5) an offense under Section 22.02, Penal Code (aggravated assault);
(6) an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
(7) an offense under Section 22.041, Penal Code (abandoning or endangering child);
(8) an offense under Section 22.08, Penal Code (aiding suicide);
(9) an offense under Section 25.031, Penal Code (agreement to abduct from custody);
(10) an offense under Section 25.08, Penal Code (sale or purchase of child);
(11) an offense under Section 28.02, Penal Code (arson);
(12) an offense under Section 29.02, Penal Code (robbery);
(13) an offense under Section 29.03, Penal Code (aggravated robbery);
(14) an offense under Section 21.08, Penal Code (indecent exposure);
(15) an offense under Section 21.12, Penal Code (improper relationship between educator and student);
(16) an offense under Section 21.15, Penal Code (improper photography or visual recording);
(17) an offense under Section 22.05, Penal Code (deadly conduct);
(18) an offense under Section 22.021, Penal Code (aggravated sexual assault);
(19) an offense under Section 22.07, Penal Code (terroristic threat);
(20) an offense under Section 32.53, Penal Code (exploitation of child, elderly individual, or disabled individual);
(21) an offense under Section 33.021, Penal Code (online solicitation of a minor);
(22) an offense under Section 34.02, Penal Code (money laundering);
(23) an offense under Section 35A.02, Penal Code (Medicaid fraud);
(24) an offense under Section 36.06, Penal Code (obstruction or retaliation);
(25) an offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to non-livestock animals); or
(26) a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

Signature(Required)

Type your full name to act as a Digital Signature.

Consent

Signature(Required)

Type your full name to act as a Digital Signature.

Date

General Information

Education

Emergency Contact Information

Standard Skills

Other Skills

Employment History

References

DPS Computerized Criminal History (CCH) Verification

Employability Consent

Consent