BVCASA | Application

To fill out application for any of the following positions;

Administrative

Professional

Services

please print out and return completed form below to:

4001 E. 29th St., Suite 90, Bryan, TX 77802

or fax to (979) 846-3213

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Brazos Valley Council on Alcohol and Substance Abuse

APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer (EOE)

Personal Info

Please print or type

Name/Last First Full Middle Name				Social Security Number
Current Address/City/State/Zip Code				Telephone Number
Po sition Applying For:			Date available for employment?
Are you willing to relocate? ( ) Yes or ( ) No	Are you willing to if required? ( ) Yes or ( ) No		Any restriction on hours, weekends, or overtime? If yes, explain.
Has this Company or any of its subsidiaries before ever employed you? ( ) Yes or ( ) No		Indicate locations and dates:
Can you, after employment, submit verification of your legal right to work in the United States? ( ) Yes or ( ) No		Have you ever been convicted of a felony? ( ) Yes or ( ) No Have you ever been convicted of a class A or B misdemeanor? ( ) Yes or ( ) No Convictions will not automatically disqualify job candidates. The seriousness of the crime and date of conviction will be considered.

Performance of Job Functions

Are you able to perform all the functions of the job for which you are applying with or without accommodation?

( ) Yes, without accommodation ( ) Yes, with accommodation ( ) No

If you indicated you can perform all the functions with an accommodation, please explain how you would perform the tasks and with what accommodation(s).

Education

School Level	School & Name Address	# of Years Attended	Did you graduate?	Course of Study
High School
Vo-Tech, Business or Trade School
College
Graduate School

Personal Driving Record If pertains to position applying for


Do you have a valid Drivers License?	Driver's license Number		Expiration Date		Issuing State
List any other state(s) in which you have had a driver's license(s) in the past?
Within the past five years have you had a vehicle accident? ( ) Yes or ( ) No		Been convicted of reckless or drunken driving? ( ) Yes or ( ) No If yes, give dates:		Been cited for moving violations? ( ) Yes or ( ) No If yes, give dates:
Has your driver's license ever been revoked or suspended? ( ) Yes or ( ) No			Is your driver's license restricted? ( ) Yes or ( ) No If yes, explain:

EMPLOYMENT HISTORY - List entire employment history, starting with your present employer. For any unemployed or self-employed periods show dates and location. (Attach additional sheets if necessary.)

Company Name:

Address:

City/State/Zip:

Phone #: ( )

Beginning Job Title:

Ending Job Title:

Description of Duties:

Supervisor:

Dates Employed

From: To:

Start Rate:

End Rate:

Reason Leaving:

May we contact employer?

Company Name:

Address:

City/State/Zip:

Phone #: ( )

Beginning Job Title:

Ending Job Title:

Description of Duties:

Supervisor:

Dates Employed

From: To:

Start Rate:

End Rate:

Reason Leaving:

May we contact employer?

Company Name:

Address:

City/State/Zip:

Phone #: ( )

Beginning Job Title:

Ending Job Title:

Description of Duties:

Supervisor:

Dates Employed

From: To:

Start Rate:

End Rate:

Reason Leaving:

May we contact employer?

Specify skills you may have. List current credentials / licenses you posess relating to position (office and/or road): _________________________________

Do you have other additional experience and training you feel would qualify you for the position? List: __________________________________

List any foreign languages you may speak, read, and/or write:

Give the names and addresses of three (3) persons otherthanrelatives, who have knowledge of your character, experience or ability:

Name	Address	Occupation	Telephone #
(1)
(2)
(3)

Military Service

Branch of Service: Dates of Service:

Type of Discharge: Rank on Entering:

Rank at Discharge: Primary Duties:

IMPORTANT - We are glad you are interested in joining the BVCASA family.

Please read the following statements carefully before you sign and return this application.

The agency, in considering my application for employment, may verify the information set forth on this application and obtain additional background information relating to my background. I authorize all persons, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any information concerning my background. I have read, understand, and agree to this statement,(Initial here.)

I understand that BVCASA has a commitment to maintain an alcohol/drug-free workplace and that BVCASA, unless prohibited by state law, requires a drug screening test as a part of its selection and hiring process. I understand that such drug screening will consist of the testing of a urine sample or other medically recognized test designed to detect traceable amounts of a controlled substance in my body. If any detectable amounts are found in my body, a second test, approved by the NIDA will be performed on the same specimen. If the results of the second test are also positive, I will be disqualified from consideration for employment and any offer of employment withdrawn. I further understand and agree that if I am employed, I may be required to submit to alcohol/drug testing under certain circumstances during my employment. I have read, understand, and agree to the statement above,(Initial here.)

I certify that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or, if employed, my dismissal. I understand that this application is not a contract, offer, or promise of employment and that if hired I will be able to resign at any time for any reason. Likewise, the agency can terminate my employment at any time with or without cause. I have read, understand, and agree to this statement, (Initial here.)

I understand that this application is good only for sixty (60) days from today's date. If I still desire a position with the agency after this application expires, it will be my responsibility to fill out a new application and file it with the agency. Otherwise, the agency will not consider me for employment after this application expires.

Signature: Date:

FOR PERSONNEL OFFICE USE ONLY

Interviewed By :

Recommendation: ( ) Hire ( ) Do Not Hire ( ) Hold For Further Interview

Comments :

* We are an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, gender, age, national origin or disability.