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Instructions  The receipt of this application does not imply any guarantee of employment. By submitting this application, this organization has my authorization to thoroughly investigate my employment and personal history (which may include information concerning my character, criminal convictions, mode of living, general reputation, personal characteristics and related pertinent information) and hereby consent to take any test, whenever the organization deems it necessary, in any employment investigation. I will hold no person, corporation or organization liable for my giving or its receiving information in such investigation. (Under Texas statute, potential employers of mental health professionals must ask current and past employers to disclose any history or instance of sexual contact, exploitation, or therapeutic deception by the applicant. Additionally, the law requires current and past employers to disclose any history or instance of abuse by the applicant. This information is sought and disclosed for the sole purpose of safeguarding the welfare of our residents). If employed, I may terminate my employment at any time, without notice or cause. If employed, I understand that employment is for no definite period of time and if terminated, the employer is liable only for wages or salaries earned as of the date of termination. In consideration of my employment, I agree to comply with the rules, regulations and policies of the employer. Any physician, hospital or testing laboratory has my consent to conduct medical examinations or drug screening test on me, and I hereby give my consent for all such information to be released for the employer to determine my abilities to perform my job, now or in the future. I also give my consent to physical searches of my brief case and myself, lunch box, vehicle, locker, purse or any packages I have while on the employer’s premises, whether or not I have a lock on such items. The needs of the employer may make the following conditions mandatory: overtime, shift work, rotating work schedules, or a work schedule other than Monday through Friday. If a conditional offer of employment is made, applicants are required to participate in a pre-employment medical exam, drug screen and criminal background investigation.

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APPLICANT CERTIFICATION & AGREEMENT: (Read carefully before signing)

I certify that this information contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I understand that if employed, misleading or falsified statements on this application may be considered cause for dismissal.

Enter your name in the text box below to sign your application and agree to these terms.
Equal Employment Opportunity
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.

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Race (do not respond if you selected "Hispanic or Latino" above)
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment
A person having origins in any of the black racial groups of Africa
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
A all persons who identify with more than one of the above five races

Protected Veterans
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran
Disabled Veteran
A "disabled veteran" is one of the following:

A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign Badge Veteran
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
Armed Forces Service Medal Veteran
An "armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Disability Status
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.


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