RED RIVER COUNTY, TEXAS
                   APPLICATION FOR EMPLOYMENT

AN EQUAL OPPORTUNITY EMPLOYER
	It is our policy to comply fully with all federal, state and local equal employment opportunity laws.  This organization provides equal employment, advancement opportunities, and access to services for all persons regardless of race, creed, sex, national origin, age, religion, disability, marital status, or any other classification protected by law.  If you need assistance completing this application and/or with any testing required during the application process, please ask the staff in the Treasurer’s Office so that assistance may be provided.  A job description will be available for your review for each job posted. 		
PLEASE  PRINT  IN  INK 
		
NAME (As it appears on Social Security Card / Work Permit Card)	

	                     Last                                                                                                      First                                                                               M.I.	
		
SOCIAL SECURITY NUMBER		

ADDRESS		

CITY, STATE, ZIP		

HOME TELEPHONE		MESSAGE CONTACT		
			Name                                                         Area Code     Number	
				
DAYTIME TELEPHONE		ARE YOU AT LEAST 18 YEARS OLD?      	 YES      NO	

OTHER NAMES YOU HAVE USED:		

POSITION 
APPLIED FOR:		 
DEPARTMENT:	

				
REFERRED FOR THIS POSITION BY:		DATE
AVAILABLE:		

HAVE YOU EVER BEEN 
EMPLOYED BY THIS ORGANIZATION?  NO    YES	WHEN?                    DEPARTMENT:	

SUPERVISOR:						REASON FOR LEAVING:
_________________________________________________________________________________________________
DO YOU HAVE A RELATIVE CURRENTLY WORKING FOR RED RIVER COUNTY?
  NO   YES   IF YES, WHAT IS HIS OR HER NAME? __________________________________________________________________________

WHAT IS YOUR RELATIONSHIP? _____________________________________________________________________________________________ 

IN WHAT DEPARTMENT DOES YOUR RELATIVE WORK? _________________________________________________________________________

			
HAVE YOU EVER BEEN CONVICTED, OR PLED GUILTY OR NO CONTEST TO, A FELONY OFFENSE?  IF SO, PLEASE EXPLAIN.  IMPORTANT:  FOR PURPOSES OF EMPLOYMENT WITH RED RIVER COUNTY, “CONVICTIONS” INCLUDE SENTENCED TO CONFINEMENT, PAID FINE, TIME SERVED, PLACED ON PROBATION (INCLUDING DEFERRED ADJUDICATION) AND COURT-ORDERED RESTITUTION. A CONVICTION WILL NOT NECESSARILY DISQUALIFY AN APPLICANT FROM EMPLOYMENT.	IF APPLYING FOR A POSITION WHICH REQUIRES DRIVING A VEHICLE, PLEASE PROVIDE THE FOLLOWING INFORMATION:

I HAVE A VALID DRIVER’S LICENSE:

   NO     YES   
 
 TYPE: ___________________________________
 
 DRIVER’S LIC. #____________________________

 STATE: __________________________________	CAN YOU, IF HIRED, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES?

     NO                    YES	
			
NO   YES 	If Yes, Give location, date, 
  	charge and disposition of 
	case(s) on a separate page		

U.S. MILITARY SERVICE
		
	If you have served in the U.S. Military, please provide the following information:

_____________________________________________
Branch of Service
	From: ____________  To: _____________		_______________________________
				Dates Served						Type of Discharge

EDUCATION / SKILLS
						
EDUCATIONAL LEVEL	
        NAME                                 CITY     STATE                 	CIRCLE YRS.
COMPLETED	UNITS
COMPLETED	
DEGREE	
MAJOR	

HIGH SCHOOL		  9    10    11    12				

COMMUNITY or 		          1      2				
JUNIOR COLLEGE		          
          1      2				

BUSINESS or
TRADE SCHOOL		          
          1      2				

		  1      2      3      4				
COLLEGE or		
  1      2      3      4				
UNIVERSITY		  
  1      2      3      4				

GRADUATE						
SCHOOL						
						
COMPUTER SOFTWARE SKILLS
			
COMPUTER SOFTWARE	Name of Software	Your Proficiency With The Software 	

       Word Processing		    Skilled            Competent          Familiar	

       Spreadsheet		    Skilled            Competent          Familiar	

       Database		    Skilled            Competent          Familiar	

       Other		    Skilled            Competent          Familiar	
			
LICENSES / CERTIFICATIONS / ORGANIZATIONS

PROFESSIONAL LICENSES	TYPES OF LICENSES and CERTIFICATES	DATE
ISSUED	REGISTRATION
NUMBER	STATE	EXPIRES
MO / YR	
and CERTIFICATIONS						
(Job Related)						

PROFESSIONAL, SCHOLASTIC and	NAME	DATE	NAME	DATE	
OTHER ORGANIZATIONS					
(Job Related)					
Exclude memberships that indicate your race, religion, color,					
national origin, ancestry, sex, age, disability or veteran status 					
JOB RELATED TRAINING
				
NAME OF COURSE	YEAR COMPLETED	NAME OF COURSE	YEAR COMPLETED	

				

				
				
EMPLOYMENT HISTORY
THIS PORTION OF THE APPLICATION MUST INCLUDE A MINIMUM OF 10 YEAR WORK HISTORY AND MUST BE COMPLETED EVEN IF SUPPLEMENTED BY A RESUME

LIST YOUR MOST RECENT EMPLOYER FIRST INCLUDING U.S. MILITARY SERVICE AND UNPAID OR VOLUNTEER WORK.
BASE SALARY DOES NOT INCLUDE OVERTIME, BONUSES OR COMMISSIONS.

FROM (Mo/Yr) ________ TO (Mo/Yr) ________  TOTAL ________ YRS ________MOS.    YOUR POSITION ________________________________
EMPLOYER: ____________________________________________________________    YOUR SUPERVISOR _____________________________
ADDRESS: ________________________________________________________________________________  PHONE ______________________
TYPE OF BUSINESS _____________________________________  REASON FOR LEAVING ___________________________________________
BASE SALARY  ___________ / __________    MONTHLY   WEEKLY   HOURLY     OTHER COMPENSATION, BONUSES ______________
                                           START                     FINAL
BRIEF DESCRIPTION OF YOUR DUTIES & RESPONSIBLITIES  __________________________________________________________________
	
FROM (Mo/Yr) ________ TO (Mo/Yr) ________  TOTAL ________ YRS ________MOS.    YOUR POSITION ________________________________
EMPLOYER: ____________________________________________________________    YOUR SUPERVISOR _____________________________
ADDRESS: ________________________________________________________________________________  PHONE ______________________
TYPE OF BUSINESS _____________________________________  REASON FOR LEAVING ___________________________________________
BASE SALARY  ___________ / __________    MONTHLY   WEEKLY   HOURLY     OTHER COMPENSATION, BONUSES ______________
                                           START                     FINAL
BRIEF DESCRIPTION OF YOUR DUTIES & RESPONSIBLITIES  __________________________________________________________________
	
FROM (Mo/Yr) ________ TO (Mo/Yr) ________  TOTAL ________ YRS ________MOS.    YOUR POSITION ________________________________
EMPLOYER: ____________________________________________________________    YOUR SUPERVISOR _____________________________
ADDRESS: ________________________________________________________________________________  PHONE ______________________
TYPE OF BUSINESS _____________________________________  REASON FOR LEAVING ___________________________________________
BASE SALARY  ___________ / __________    MONTHLY   WEEKLY   HOURLY     OTHER COMPENSATION, BONUSES ______________
                                           START                     FINAL
BRIEF DESCRIPTION OF YOUR DUTIES & RESPONSIBLITIES  __________________________________________________________________
	
FROM (Mo/Yr) ________ TO (Mo/Yr) ________  TOTAL ________ YRS ________MOS.    YOUR POSITION ________________________________
EMPLOYER: ____________________________________________________________    YOUR SUPERVISOR _____________________________
ADDRESS: ________________________________________________________________________________  PHONE ______________________
TYPE OF BUSINESS _____________________________________  REASON FOR LEAVING ___________________________________________
BASE SALARY  ___________ / __________    MONTHLY   WEEKLY   HOURLY     OTHER COMPENSATION, BONUSES ______________
                                           START                     FINAL
BRIEF DESCRIPTION OF YOUR DUTIES & RESPONSIBLITIES  __________________________________________________________________
	
FROM (Mo/Yr) ________ TO (Mo/Yr) ________  TOTAL ________ YRS ________MOS.    YOUR POSITION ________________________________
EMPLOYER: ____________________________________________________________    YOUR SUPERVISOR _____________________________
ADDRESS: ________________________________________________________________________________  PHONE ______________________
TYPE OF BUSINESS _____________________________________  REASON FOR LEAVING ___________________________________________
BASE SALARY  ___________ / __________    MONTHLY   WEEKLY   HOURLY     OTHER COMPENSATION, BONUSES ______________
                                           START                     FINAL
BRIEF DESCRIPTION OF YOUR DUTIES & RESPONSIBLITIES  __________________________________________________________________
	
(ATTACH ADDITIONAL PAGE IF NECESSARY)

EXPLANATION OF INTERRUPTIONS IN EMPLOYMENT HISTORY
Please use this space to explain employment history interruptions since high school that do not pertain to pregnancy, child care, disability or any other protected activity.
_______________________________________________________________________________
_______________________________________________________________________________
	
(ATTACH ADDITIONAL PAGE IF NECESSARY)
REFERENCES
NAME _____________________________________________________
ADDRESS  _________________________________________________
CITY,STATE,ZIP_____________________________________________
DAYTIME PHONE ___________________________________________
RELATIONSHIP _____________________________________________
                                                                                (No Relatives)	NAME _____________________________________________________
ADDRESS  _________________________________________________
CITY,STATE,ZIP_____________________________________________
DAYTIME PHONE ___________________________________________
RELATIONSHIP _____________________________________________
                                                                                (No Relatives)	
NAME _____________________________________________________
ADDRESS  _________________________________________________
CITY,STATE,ZIP_____________________________________________
DAYTIME PHONE ___________________________________________
RELATIONSHIP _____________________________________________
                                                                                (No Relatives)	NAME _____________________________________________________
ADDRESS  _________________________________________________
CITY,STATE,ZIP_____________________________________________
DAYTIME PHONE ___________________________________________
RELATIONSHIP _____________________________________________
                                                                                (No Relatives)	
AUTHORIZATION AND AGREEMENT                                        

I HEREBY AUTHORIZE YOU TO CONTACT:  	MY PRESENT EMPLOYER(S):	 YES   NO          
						MY PAST EMPLOYERS:  		 YES   NO

As part of our normal procedure in processing applications, a routine inquiry will be made concerning your background.  Former employers, school record offices and personal, school and employment references may be contacted by a consumer reporting agency or County personnel to verify and obtain information concerning your background, qualifications, school and work records.  You may be asked to sign another form authorizing the release of school records or to supply grade transcripts.  Information gathered about your background and qualifications will be used to help make a fair employment decision.  This information will only be available to those participating in this decision or those who process employment applications.  As part of this investigation, a consumer reporting agency or County personnel may also conduct a check of criminal conviction records.  This agency may keep and use information it supplies to us in this investigation for its own business purposes.  Further information such as the name of the consumer reporting agency or the nature and scope of such inquiry, if one is made, is available to you upon written request.  You will also be given a separate disclosure and authorization to review and sign concerning any reports prepared about your background for us by a consumer-reporting agency that compiled the report.
	
I hereby authorize the employer, its representatives, employees or agents to conduct all pre-employment inquiries and tests as described.  I further authorize the employer and its agents to verify all statements contained in this application and any other materials I submit in connection with my employment application.  I agree to complete any requisite authorizations forms.  I release the employer, its agents and all providers of information from any liability arising out of the gathering and use of such information.  In the event of employment, this authorization and release is valid throughout my employment and a photocopy is as effective as the original.  

I understand all offers of employment are conditional upon satisfactory reference checks, successful completion of all pre-employment tests and production of all documents necessary for the employer to verify my identity and work authorization in accordance with the requirements of the Immigration and Naturalization Services.

As an employer, this organization is subject to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.  Applicants who believe they are covered by these Acts are invited to identify their disabilities and special accommodations they feel are necessary to adequately perform their jobs.  Submission of this information is strictly voluntary and may be made to the Personnel Director.

I certify the information provided in this application is true and complete to the best of my knowledge.  I understand withholding pertinent information or submitting false or misleading information on this application, my resume, during interviews or at any other time during the hiring process constitutes valid grounds for disqualification from further consideration for hire or immediate dismissal from employment and loss of all employee benefits and privileges.  I further understand and agree that the employer shall not be liable in any respect if my employment is so denied or terminated.

I understand and agree to immediately notify Red River County if I am convicted of, received deferred adjudication in, or otherwise plead guilty or no contest to a felony, or any crime involving dishonesty or a breach of trust while my application is pending or during my period of employment, if hired.

I understand and agree that if I am applying for a law enforcement or jail position, I will be required to comply with all the requirements of the Texas Commission on Law Enforcement Officer Standards and Education or other equivalent agency as required by the State.  I further understand that any offer of employment is conditioned upon completing all those tests, including physical agility, to determine my fitness for this position.

I understand and agree that, if required for the position, I will submit to a pre-employment driving record check and/or pre-employment physical, and in accordance with the County’s adopted policies, I will submit to a pre-employment drug/alcohol screen as well as any other drug/alcohol screenings as required by the County’s policy.  I understand and agree that, if I refuse to submit to such physical, drug/alcohol screen, or driving record check, I will not be considered for employment with Red River County.  I also understand that, once employed, refusal to submit to such exams or a positive result on a drug/ alcohol screen will be grounds for disciplinary action, which may include termination.

I understand the acceptance of this application by the employer neither expresses nor implies I will be offered employment.  I understand my employment is at will and I may resign at any time for any reason; similarly, my employment may be terminated by the organization at any time for any reason.  Any changes to this at-will employment agreement will not be valid unless in writing signed by me and a duly authorized representative of this employing organization.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE AUTHORIZATION AND AGREEMENT STATEMENTS.

SIGNATURE OF APPLICANT________________________________________________________  DATE ____________________
	
AUTHORIZATION AGREEMENT NOTARIZATION

STATE OF TEXAS         §

COUNTY OF RED RIVER    §

          BEFORE ME, the undersigned, a Notary Public in and for Red River County, Texas, on this day personally appeared
_________________________________________________________, known or proven to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he/she executed the same for the purpose and consideration therein expressed.

          GIVEN UNDER MY HAND AND SEAL OF OFFICE on this the _________ day of ________________________,
20______.

             (SEAL)                                                  __________________________________________________________
                                                               Notary Public Signature

                                                                           My Commission Expires:______________________________________

PLEASE NOTICE:  	ONLY THOSE APPLICANTS SELECTED FOR INTERVIEWS WILL BE NOTIFIED OF THEIR SELECTION OR NON-SELECTION FOR EMPLOYMENT WITH RED RIVER COUNTY.

APPLICATIONS ARE KEPT ON FILE FOR ONE (1) YEAR, BUT ARE CONSIDERED CURRENT FOR SIX (6) MONTHS.

VOLUNTARY CONSENT TO PRE-EMPLOYEMENT DRUG TESTING

Applicant Name:___________________________________________________________________
                                                                           (Please Print)

Red River County has a vital interest in maintaining safe, healthful and efficient working conditions for its employees.  Using or being under the influence of drugs may pose serious safety and health risks not only for the user but for his/her co-workers and the public, as well.

By signing this Notice, the applicant understands and voluntarily agrees to submit to pre-employment drug screening.  The applicant further agrees to release Red River County and its directors, officers, agents, employees, subsidiaries and affiliated concerns from any and all liability, claims, demands, damages and causes of action of every kind and nature arising out of the pre-employment drug screening and any decision concerning employment made by Red River County, in whole or in part, based upon the results of the pre-employment drug screen.

ANY APPLICANT WHO IS UNWILLING TO AGREE TO THESE CONDITIONS SHOULD NOT APPLY FOR EMPLOYMENT WITH RED RIVER COUNTY.  Refusal of any applicant to agree to pre-employment drug screening at this time does not preclude an applicant from applying for employment with Red River County at some future time when the applicant will agree to conform to our policies.

I understand that my offer of employment with Red River County is contingent upon my taking and passing a test for the presence of illegal drugs.  I further understand and agree that I may be terminated from Red River County should the results be positive for the presence of illegal drugs.  I voluntarily consent to have a sample of my urine collected for the purpose of drug testing.  In the event I should submit two or more samples for drug screening in connection with my application for employment, I understand that each sample must be negative for the presence of illegal drugs.  The drug test will be conducted by a clinical, SAMHSA certified laboratory.  I hereby authorize the results of this testing to be released to Red River County.  This consent is subject to revocation at any time upon written notice.  I understand that I may receive a copy of this consent form upon written request.

Signature of Applicant:_____________________________________________________________

Date:________________________________________

(To be maintained on file with Employment Application)