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PLEASE READ CAREFULLY
Note: Fields marked with a * require an answer. Please use "N/A" for "not applicable" if necessary. Applicants may be required to complete and sign a paper application for employment upon interview.

Applicant Resume

Attach Resume:
*Email:
Applying for:

Applicant Information

*First Name: *Last Name:
*Address: Apartment/Unit #
*City *State
*Zip
*Phone: Referred By:
Date Available: Salary Expected:
I can work:  Weekends    Evening    Night
U.S. Citizen:    Yes     No If not, are you authorized to work in the U.S.?:    Yes     No
Driver's License State: Driver's License Number:
*Have you ever worked for this company?:    Yes     No
If yes, when?: ------ To ------
*Have you ever been arrested or convicted of a misdemeanor/felony that is related to the functions or qualifications of the position for which you are applying?
(A conviction record will not necessarily be a bar to employment):
   Yes    No If yes, please describe fully the misdemeanor/felony conviction(s) listing the nature of the offense(s) and your rehabilitation since the conviction(s):

Education

High School: Address:
Graduate: Yes   No Degree:
College: Address:
Graduate: Yes   No Degree:
Other: Address:
Graduate: Yes   No Degree:

References

Please list the names of three (3) persons (other than relatives) who have a definite knowledge of your ability and character. Please give their present address and a daytime telephone number.
Name: Relationship:
Company: Day Phone Numbers:
Address:
Name: Relationship:
Company: Day Phone Numbers:
Address:
Name: Relationship:
Company: Day Phone Numbers:
Address:

Employment History

Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
  End Date:
 
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No

Military Service

Start Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
Branch: Rank at Discharge:
Type of Discharge: If other than honorable, explain:

Applicant's Statement

Notification and Agreement

I hereby affirm that all information in this application is true and accurate to the best of my knowledge. I understand that the college can obtain criminal history record information on applicants for employment. Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report+ may be made in connection with your application for employment. I understand that any misrepresentation or falsification of this record or failure to disclose conviction for a felony or for any offense involving moral turpitude will be considered cause for dismissal.

If you are denied employment, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer-reporting agency making such report.

Signature below verifies you have read the above notice and understand what it means.

Submit
Company Name: Complete Address
(w/ City, State, Zip):
Phone: Supervisor:
Job Title: Responsibilities:
Starting Salary: Ending Salary:
Start Date:
  End Date:
 
Reason for Leaving: May we contact your previous employer for a reference?  Yes    No
Northeast Texas Public Health District

815 N. Broadway Ave
Tyler, Texas 75702

903-535-0030

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