Join Our Team|Cheyenne Center

Date

PERSONAL:

Last Name

Middle Init.

First Name

Current Address

City

State

ZIP Code

Phone

Email Address

Are you over 18? YesNo

Are you a citizen of the U.S. or do you have the legal right to be employed in the United States? YesNo

Have you ever been convicted of any crime (excluding minor traffic violations) including: driving while under the influence of alcohol or drugs or any sexual related or child abuse related offenses? YesNo

IF YES, state the offense, location, date and disposition: (NOTE: A conviction will not necessarily disqualify you from employment.)

Have you ever been employed by The Texas Department of Criminal Justice? YesNo

Have you ever applied to our company before? YesNo

Have you ever worked for our company before? YesNo

IF YES, state when and where you applied and/or worked:

Are you, or have you ever been, related to anyone who is employed, or has ever been employed, by Cheyenne Center, Inc? YesNo

EMPLOYMENT DESIRED:

Are you seekingFull TimePart TimeTemporary or summer employment

Position applied for:

Salary Desired:

Date Available to start:

How did you learn of our company and/or position?

Are there any days or hours you would be unable or unwilling to work?YesNo

IF YES, please specify those days or hours you would be unable or unwilling to work:

EDUCATION:

High School:

(Name, Address and Location)

Graduate? YesNo

Grade

College:

(Name, Address and Location)

Graduate? YesNo

Years

Major:

Degre:

MILITARY:

Have you ever served in the military? YesNo

Service Branch:

Final Rank:

Date Entered:

Date Separated:

WORK HISTORY:

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.

DO NOT REFERENCE YOUR RESUME.

Name of Employer:

Dates Employed From:

Dates Employed To:

Starting Pay:

Ending Pay:

Address

City

State

ZIP Code

Telephone:

Reason for Leaving:

Nature of Business:

Name and Title of Last Supervisor:

Describe duties performed, skills used/learned, advancements/promotions earned:

DO NOT REFERENCE YOUR RESUME.

Name of Employer:

Starting Pay:

Ending Pay:

Dates Employed From:

Dates Employed To:

Address

City

State

ZIP Code

Telephone:

Reason for Leaving:

Nature of Business:

Name and Title of Last Supervisor:

Describe duties performed, skills used/learned, advancements/promotions earned:

DO NOT REFERENCE YOUR RESUME.

Name of Employer:

Dates Employed From:

Dates Employed To:

Starting Pay:

Ending Pay:

Address

City

State

ZIP Code

Telephone:

Reason for Leaving:

Nature of Business:

Name and Title of Last Supervisor:

Describe duties performed, skills used/learned, advancements/promotions earned:

SUPPLEMENTAL EMPLOYMENT INFORMATION:

Are you presently employed? YesNo

If yes, may we contact your present employer?YesNo

Have you engaged in sexual abuse in a jail or prison, been convicted of engage or attempting to engage in sexual activity in the community facilitated by force, YesNo

Have you ever had any sexual misconduct convictions or been involved in any substantiated incidents of sexual harassment? YesNo

REFERENCES:

(Give three references, not relatives or former employers.)

Name

Occupation:

Telephone:

Address

City

State

ZIP Code

Name

Occupation:

Telephone:

Address

City

State

ZIP Code

Name

Occupation:

Telephone:

Address

City

State

ZIP Code

AFFIDAVIT:

I certify that my answers to the foregoing questions are true and correct without any consequential omissions of any kind whatsoever. I understand that if I am employed, any false, misleading or otherwise incorrect statements made on this application form or during any interviews may be grounds for my immediate discharge.

I hereby authorize Cheyenne Center, Inc. to contact any company or individual it deems appropriate to investigate my employment history, character and qualifications and I give my full and complete consent to their revealing any and all information they wish as a result of this investigation. I also understand that my employment is “at-will” and may be terminated by myself or by the company at any time for any reason or no reason at all, with or without prior notice.

SIGNATURE:

Type your name

DATE: