Job Application and Criminal Background Check

Physical Address:140 Smirl Drive, Heath, TX 75032 

 

 

 

Instructions: Print clearly in black or blue ink. Answer all questions. Sign and date the form.

 

 

__________________________________________________________________________________________

Last Name                                       First Name                                                        Middle Name

 

 

__________________________________________________________________________________________

Street Address                                            City, State                                                         Zip Code

 

__________________________________________________________________________________________

Phone Number                                            Alternate Phone Number                           Social Security Number

 

 

Position Applied For ________________________________________________________________________

 

Are you eligible to work in the United States? Yes ___ No___   

 

Have you been convicted of or pleaded no contest to a felony?                 Yes____________ No___________

 

Days Available: Mon ________ Tue ______ Wed ______ Thu _______ Fri ______ Sat _____ Sun ________

Hours Available: From____________________________To________________________________________

 

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

Employer: _________________________________________________________________________________

 

Address: __________________________________________________________________________________

 

Position Title: ____________________________Phone________________ From/To:____________________

 

Responsibilities: ____________________________________________________________________________

 

Reason for Leaving: _________________________________________________________________________

 

Employer: _________________________________________________________________________________

 

Address: __________________________________________________________________________________

 

Position Title: ______________________________Phone________________ From/To: __________________

 

Responsibilities: ____________________________________________________________________________

 

Reason for Leaving: _________________________________________________________________________

 

May We Contact your Present Employer?    Yes______      No________

 

References:    Name/Title Address Telephone

 

1) ________________________________________________________________________________________

 

 

2) ________________________________________________________________________________________

 

3) ________________________________________________________________________________________

 

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

 

 

 

 

 

I, __________________________________________, am an applicant for employment / volunteer work with ___________________________ church and have been advised that as a part of the application process, the church conducts a criminal history background check.  I do hereby consent to the church use of any information provided during the application process in performing the criminal history check. The church has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment / volunteer work.  In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the church.  Under the fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of all information.

The following are my responses to questions about my criminal history (if any).

 

1. ____YES ____NO   Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (exclude minor traffic misdemeanors). 

If yes, please provide details below.

 

 

2. ____YES ____NO   Have you ever-received deferred adjudication or similar disposition for any federal, state or municipal offense?

If yes, please provide details below.