*Denotes required information
First Name* :
Last Name* :
Date of Birth (mm/dd/yyyy)* :
Street Address* :
City* :
State* :
Zip* :
Phone Number* (xxx-xxx-xxxx) :
2nd Phone Number (xxx-xxx-xxxx) :
E-mail Address* :
Date Available to Start (mm/dd/yyyy)* :
Social Security Number (xxx-xx-xxxx)* :
Are you 18 years of age or older?* :
If you are under 18 years of age, can you provide a work permit? :
If no, please explain :
Are you legally allowed to work in the United States?* :
Summarize your skills or qualifications (200 characters max) :
Dates of Employment (mm/dd/yyyy)* : From:
To:
Name of Company* :
Supervior's Name* : First:
Last:
Phone Number* (xxx-xxx-xxxx) :
May we contact this employer for a reference?* :
If no, please explain :
Dates of Employment (mm/dd/yyyy)* : From:
To:
Name of Company* :
Supervior's Name* : First:
Last:
Phone Number* (xxx-xxx-xxxx) :
May we contact this employer for a reference?* :
If no, please explain :
Dates of Employment (mm/dd/yyyy)* : From:
To:
Name of Company* :
Supervior's Name* : First:
Last:
Phone Number* (xxx-xxx-xxxx) :
May we contact this employer for a reference?* :
If no, please explain :
The items of personal information requested below are needed to process your background investigation. This information is intended solely for that purpose and will not be used in a discriminatory manner by the parties noted below in the making of appropriate business decisions.
Driver's License #* :
DL State* :
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Have you ever been convicted of a crime {other than traffic offenses}?* :
If yes, please explain charges :
What State, County, and What Year did these convictions occurr? :
If other, please specify :
By checking the box next to "I Agree" and then clicking "Submit", I am certifying that I have made no misrepresentation in this application and I have not withheld information in my statements and answers to questions. I hereby release Hill Country Care Providers to investigate and verify any representations made by me, either orally or in writing. I hereby release Hill Country Care Providers and any individual who provides or obtains information pursuant to this authorization, from any and all liability for damages of any kind which may result to me on account of compliance, or attempts to comply, with this authorization. I am aware that my misrepresentations may cause my application to be rejected or may cause dismissal if I am hired before such misrepresentations are discovered. I am also aware that my application is subject to the Texas open records law and may be released as a public document. I also understand that this application is the property of Hill Country Care Providers and will become a part of my personnel file if I am hired.I Agree*
