DSSW / CDS / LSHC Employment Application

Application for Employment
The Agency does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, age disability, or any other legally protected status.

The Agency is an equal opportunity employer.
Date of Application

MonthDayYear
Date
Office Location

CDS in TexasDSSW AustinDSSW BeaumontDSSW DallasDSSW El PasoDSSW Fort WorthDSSW HendersonDSSW HoustonDSSW LongviewDSSW OdessaDSSW San AntonioDSSW TempleLifeSpan AustinLifeSpan BeaumontLifeSpan DallasLifeSpan El PasoLifeSpan Fort WorthLifeSpan HendersonLifeSpan HoustonLifeSpan LongviewLifeSpan OdessaLifeSpan San AntonioLifeSpan TempleOther
Position Desired*
Phone Number
Please enter a valid phone number.
Or enter another title:
Name*

First NameMiddle NameLast Name
Maiden/Alias (If Applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security Number*
XXX-XX-XXXX
How did you learn about the position you are applying for?

Newspaper AdWalk-inInternet PostingCurrent EmployeeReferred by ClientCare.comOther
Which News Paper Ad?
Who is the current employee?*
Have you ever been convicted of a felony or misdemeanor? (Answering yes may not automatically disqualify you)*

NoYes
Please Explain:*
Have you ever been employed by the Agency?*

NoYes
When?*
What Position*
Reason for leaving?*
Do you currently have any relatives employed by the Agency?*

NoYes
Who is the relative employed by the Agency?*

Education:

	Name	Number of years completed	Degree/Diploma Certification	Graduated?	Major Course of Study
High School
College
Graduate School
Other

Do you hold any Professional License:*

YesNo

Have any of your Professional licenses ever been revoked, suspended, or investigated?*

NoYes
If Yes, please explain:*

Acknowledgement and Signature
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also understand and agree that any falsified information or significant omissions may disqualify me from further consideration for employment and, if discovered after I am hired, may result in dismissal.

I also understand that if employment is offered and accepted, such employment is not for any specified term and can be terminated at anytime, with or without cause, by either the Agency or myself. I further understand that this application is not a contract of continued employment, and that my at-will employment status cannot be changed.

In consideration of my being considered for employment, I authorize a thorough investigation of my past employment. I agree to cooperate in such investigation, and release from all liability or responsibility all persons and businesses requesting or supplying such information.

I understand that the Agency requires that a Criminal History Check, Employee Misconduct Registry, and OIG searches will be conducted on persons to whom an offer of employment is made. By signing this application, I acknowledge that I have been informed by the agency that a Criminal History Check, Employee Misconduct Registry, and OIG searches will be performed and EMR/NAR are searched annually. I have also informed the agency of all names, (i.e., maiden, aliases) that I have used in the past.

I understand that the Agency does not subscribe to the Worker’s Compensation plan. I further understand that the Agency does provide an occupational injury plan which may provide certain medical benefits to its employees who are injured on the job.
Signature*

Clear
Date*

MonthDayYear
Date

Reference Verification
Reference Check 1 - Name:*
Company or Personal Relationship*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reference Type*

Personal ReferenceCompany Reference
Reference Check 2 - Name:*
Company or Personal Relationship*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reference Type*

Personal ReferenceCompany Reference
Reference Check 3 - Name:*
Company or Personal Relationship*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Reference Type*

Personal ReferenceCompany Reference
I hereby authorize the release of information requested on this form.
Signature*

Clear
Date*

MonthDayYear
Date

Statement of Employability
By execution of this document, I acknowledge that I have been informed by the agency that a criminal history, an EMR/NAR, and State and Federal OIG checks will be performed on my name(s). In addition, if I am hired, the agency will verify EMR/NAR annually, and OIG (State & Federal) monthly. I have informed this agency of all names (i.e., maiden name, aliases) that I have used in the past. I hereby profess that I have not been convicted of any of the following crimes which are a permanent automatic bars to employment by this agency. The EMR is governed by 40 TAC Chapter 93 and Texas Health & Safety Code Chapter 253.

A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed below:

(1) Chapter 19, Penal Code (criminal homicide)

(2) Chapter 20, Penal Code (kidnapping & unlawful restraint);

(3) Section 21.11, Penal Code (indecency with a child); or Section 21.02, Penal Code (continuous sexual abuse of young child or children)

(4) Section 22.011, Penal Code (sexual assault);

(5) Section 22.02, Penal Code (aggravated assault);

(6) Section22.04; Penal Code (injury to a child, elderly individual, or disabled
individual);

(7) Section 22.041, Penal Code (abandoning or endangering a child);

(8) Section 22.08, Penal Code (aiding suicide);

(9) Section 25.031, Penal Code (agreement to abduct from custody);

(10) Section 25.08, Penal Code (sale or purchase of a child);

(11) Section 28.02; Penal Code (arson);

(12) Section 29.02, Penal Code (robbery);

(13) Section 29.03, Penal Code (aggravated robbery);

(14) Section 21.08, Penal Code (indecent exposure);

(15) Section 21.12, Penal Code (improper relationship between educator and student);

(16) Section 21.15, Penal Code (improper photograph or visual recording);

(17) Section 22.05, Penal Code (deadly conduct);

(18) Section 22.021. Penal Code (aggravated sexual assault);

(19) Section 22.07, Penal Code (terroristic threat);

(20) Section 32.53, Penal Code (exploitation of child, elderly individual, or disabled
Individual);

(21) Section 33.021, Penal Code (online solicitation of a minor);

(22) Section 34.02, Penal code (money laundering);

(23) Section 35A.02, Penal Code (Medicaid fraud)

(24) Section 36.06, Penal Code (obstruction or retaliation);

(25) Section 42.09, Penal Code (cruelty to livestock animals); or Section 42.092, Penal Code (cruelty to non-livestock animals);

(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 in this subsection.

A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is convicted of:

(1) Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;

(2) Section 30.02, Penal Code (burglary);

(3) Chapter 31, Penal Code (theft), that is punishable as a felony;

(4) Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;

(5) Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;

(6) Section 37.12, Penal Code (false identification as peace officer); or

(7) Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes
the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5 (c), Article 42.12, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that this offense(s) may also bar my employment. Also, if I am found to have been
reported to the Employee Misconduct Registry and/or OIG Excluded party Lists (State and/ or Federal), this offense(s) will also bar my employment.

I understand that all information obtained by this agency regarding any criminal history and employee misconduct will remain confidential. I have the right to contact DPS, DADS, and/or OIG to request an opportunity to be heard concerning the accuracy of the recorded information that was disclosed to the agency.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.
Name (Last, First, Middle)*
Date of Birth*

MonthDayYear
Date
Race/Ethnicity*
Sex*

MaleFemale
Signature*

Clear
Date*

MonthDayYear
Date

DPS Computerized Criminal History (CCH) Verification
I,{name148}, acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure
Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB
method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.dps.texas.gov /Crime Records Information/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-4672080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below,
and pay a fee of $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

(This copy must remain on file by this agency. Required for future DPS Audits)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Type of License	Agency/State Issued	Date Issued	Expiration Date	License Number
License 1
License 2
License 3

Application for Employment

Employment History

Acknowledgement and Signature

Reference Verification

Statement of Employability

DPS Computerized Criminal History (CCH) Verification