Employment Application

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 Resources Department.

Work Location: Disability Resources. Inc.

Name:

Address:

Contact:

Emergency Contact:

If you are under the age of 18, and it is required, can you furnish a work permit?

I am certifying that I am able to perform the essential function of the job, for which I applying, with or without reasonable accommodation, as described to me during the application process and through any printed material made available to me.

Have you ever been employed here before? If yes, give dates and positions.

Are you legally eligible for employment in this country?

Type of employment desired

Full timePart TimeTemporarySeasonalEducation Co-Op

Are you able to meet the attendance requirements of the position?

Have you ever plead "guilty" or "no contest" to, or been convicted of a felony?

If yes, please provide date(s) and details.


ANSWERING YES TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, FACTORS SUCH AS DATE OF
THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN
INTO ACCOUNT.

Employment History

Provide the following information of your past two (2) employers, starting with the most recent.

Employer 1




Summarize the nature of the work performed and job responsibilities.


Employer 2




Summarize the nature of the work performed and job responsibilities.


Skills and Qualifications

Summarize any training, skills, license and/or certifications that may qualify you as being able to perform
job-related functions in the position for which you are applying.


Education Background

High School

Did you graduate?

College

Did you graduate?

Other

Did you graduate?

Business References







I certify that all information I have provided in order to apply for and secure work with tiie employer is
true, complete and correct. I understand that consideration for employment is conditioned upon the results of
a reference check, and that the company Disability Resources, Inc. is authorized to investigate all
statements by the applicant upon the application and to contact former employers and references.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in
any respect will be sufficient cause (1) to cancel further consideration of this application or (2) immediate
discharge from the employer service, whenever it is discovered.

I understand dial a drug lest may be required after an offer of employment has been made as a condition of
employment.

I understand that this application will remain current for only 60 days.

I understand that I am an “at will” employee, that either I or the employer can terminate my employment for
any reason, with or without notice or cause.

I also understand that if I am hired, I will be required to provide proof of identity and legal
authorization to work in the United States and that federal immigration laws require me to complete a DHS
Employment Eligibility Verification Form.

This agreement supersedes any and all agreements, written or oral, regarding your employment. Your
employment will be governed by the laws of Texas.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENTS.

I CERTIFY THAT I HAVE READ, FULLY UNDERSTAND AND ACCEPT ALL OF THE FOREGOING APPLICANT STATEMENTS.

Disability Resources, Inc.

AUTHORIZATION FOR CONSENT FOR RELEASE OF INFORMATION (PLEASE READ CAREFULLY)

I hereby authorize my employer and any of its agents / designated company personnel, to disclose orally and in
writing, the results of tins verification process and to interview the designated authorized representative of
this company.

I have read and understand this release and consent, and I authorize the background verification. I authorize
persons, schools, current and former employers, personal references, and other organizations and agencies to
provide my employer with all information that may be requested, and to conduct a verification, as deemed
necessary by this company to fulfill the job requirements, with regards to my past work history, motor vehicle
records, credit history, workers’ compensation insurance claims as allowed by FCRA, EEOC and ECO A, and to
receive any criminaj history record information pertaining to which may be in the files of any Federal, State or
Local criminal justice agency in Texas or any other states. I hereby release all of the persons and agencies
providing such information from any and all claims and damages connected with their release of any requested
information. I agree that any copy of this document is as valid as the original. All results will be proprietary
and will be kept CONFIDENTIAL and disclosed orally and in writing only to tire designated authorized
representative of the company and its clients.

I do hereby agree to forever release, and indemnify my employer and their associates to the full extent
permitted by law from any claims, damages, losses, liabilities, cost and expense, or any other charge of
complaint with any agency arising from the retrieving and reporting of information.





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