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. Date 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 www.gchd.org 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): PERSONAL 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 process. REFERENCES 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 Business/Trade -Yes -No /Technical 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 www.gchd.org COMPLETION OF INFORMATION BELOW IS VOLUNTARY 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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