Resumes are not accepted without a completed application by omq25257


									           Galveston County Health District

 Resumes are not accepted without a completed application.
     Faxed or e-mailed applications are not accepted.

Original applications are kept active for the remainder of the
    calendar year (January 1st through December 31st).

                First Time Applicants
    Fill out entire application including “Position Routing
                         Request” Form

                Returning Applicants

         Fill out “Apply for Additional Positions” only

                          Thank You,

                      Human Resources
Galveston County Health District
Position Routing Request

Please complete this form and submit with your application. List the position number and job title
for each position for which you are applying.


Last Name                                First Name                               Middle Initial

                                                               For Office Use Only
Position Number     Job Title                         Routed/Date      Notes
                                        Galveston County Health District
                                                      Application for Employment
                                                  PO Box 939, La Marque, Texas 77568
                                                        Phone: (409) 938-2260

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable
accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

Referral Source:        Newspaper          Walk-in         Employee/Relative      Company Website              Employment Agency            Other

Name of Source (if applicable):

Full Name                                                                                                                  Date of Application

Street Address                                                          City                           State               Zip

Social Security #                   Home Telephone                                                     E-mail Address

Date available to work:                                                 Are you at least 18-years of age?         -Yes      -No

May we contact you at work?                -Yes      -No     If yes, work number and best time to call:
Have you ever been employed here before?              -Yes    -No       Do you have any relatives working here?             -Yes      -No

If yes, give dates and positions:                                       If yes, please state Name and Department:

                                                                        Type of employment desired:
What is your desired salary range?
                                                                           Full-time       Part-time          Temporary          Educational
Do you have a valid Texas Driver’s License?           -Yes     -No      Will you travel if job requires it?     -Yes      -No

Are you legally eligible for employment in this country?        -Yes    -No

Are you currently under indictment for or have you ever pled guilty, no contest or been convicted of a felony or misdemeanor by a
civilian or military court, or participated in deferred adjudication? (excluding traffic tickets)      -Yes     -No
If yes, please provide dates and details of all events:

A prior conviction will not necessarily preclude further consideration for employment. Factors such as the type of event, when It
occurred and how it relates to the job being sought will be considered. However, failure to list all events will terminate the application

List name and telephone number of three business/work references who are not related to you.
            Name                          Telephone Number                                      Number of Years Known

                                    (      )

                                    (      )

                                    (      )
                                                EDUCATIONAL BACKGROUND
                                                                             Name of school where you received your high school diploma:

Do you have a high school diploma or GED?                    -Yes      -No
                                                                             Name of institution where you received your GED:

                            Name and Location                Course of       # of Years         Did you              Degree or Diploma
 Type of School
                               of School                      Study          Completed         Graduate?                 Received

Graduate                                                                                       -Yes    -No

College                                                                                        -Yes    -No

                                                                                               -Yes    -No
List any scholarships, academic honors or special achievements:

                                                 LICENSURE / CERTIFICATION
If a license, certificate, or other authorization is required or related to the position for which you are applying, complete the following:
    License/Certification              Date Issued            Date Expires             Issuing Authority               License Number

                                                SKILLS AND QUALIFICATIONS
Summarize any special training or skills that may qualify you as being able to perform job-related functions in the position for which you
are applying.

                                                  ADDITIONAL INFORMATION
List any other additional information you would like us to consider.

                                                                                                                                Revised 10/05
                                                  EMPLOYMENT HISTORY
Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent
(use additional sheets if necessary). This section must be completed.
Employer                                              Telephone                                               Dates Employed
                                                                                                          From                To
Complete Address

Job Title                                                                                                          Rate of Pay
                                                                                                           Starting            Final
Immediate Supervisor and Title
                                                                                                     $                   $
Specific Reason for Leaving
                                                                     May we contact for reference?       -Yes    -No     -Later
Description of Job Duties

Employer                                              Telephone                                                Dates Employed
                                                                                                            From             To
Complete Address

Job Title
                                                                                                                   Rate of Pay
                                                                                                           Starting            Final
Immediate Supervisor and Title
                                                                                                     $                   $
Specific Reason for Leaving
                                                                    May we contact for reference?        -Yes   -No     -Later
Description of Job Duties

Employer                                              Telephone                                                Dates Employed
                                                                                                            From             To
Complete Address

Job Title                                                                                                          Rate of Pay
                                                                                                           Starting            Final
Immediate Supervisor and Title
                                                                                                     $                   $
Specific Reason for Leaving
                                                                    May we contact for reference?        -Yes   -No     -Later
Description of Job Duties

                                                  APPLICANT STATEMENT
     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 shall 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 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.

Signature of Applicant                                                                    Date

                                                                                                                             Revised 10/05
                              Galveston County Health District
                                                Voluntary Information
                                        1207 Oak Street, La Marque, Texas 77568
                                      Phone: (409) 938-2401 Fax: (409) 938-2243

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age or
physical disabilities, veteran/national guard or any other similarly protected status. We also comply with all applicable
laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filled separately from application.

In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which
may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY.
Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring
decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

                                            APPLICANT INFORMATION
Position(s) Applied For                                                            Date of Application

Full Name                                                                          Home Telephone

Street Address                                                   City                             State        Zip

   -Male         -Female                                         Age

Please check one of the following:
  -White (not of Hispanic origin)            -American Indian/Alaskan Native           -Black (not of Hispanic origin)
  -Asian/Pacific Islander                    -Hispanic                                 -Other

Check if any of the following are applicable:
  -Disabled (Note 1)                     -Vietnam Era Veteran (Note 2)                 -Disabled Veteran (Note 3)

Note 1 – DISABLED – “Disabled individual” means any person who (1) has a physical or mental impairment
which substantially limits one or more of such person’s major life activities, (2) has a record of such
impairment, or (3) is regarded as having such an impairment.

Note 2 – VIETNAM ERA VETERAN – “Vietnam Era Veteran” means a person who (1) served on active duty
for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and
was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from
active duty for a service-connected disability if any part of such active duty was performed between August 5,
1964 and May 7, 1975.

Note 3 – DISABLED VETERAN – A disabled veteran is a person entitled to disability compensation under laws
administered by the VA for disability rated at 30 percent or more, or a person whose discharge or release from
active duty was for a disability incurred or aggravated in the line of duty.

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