*Required* - Please be sure to complete all fields marked with an asterisk (*).

Position(s) Applied For *

How Did You Hear About Us?

If other ...

First Name *

Middle Name

Last Name *

Phone Number *

Email *

Address line 1 *

Address line 2

City *

State *

Zip code *

Have you ever filed an application with us before?

Have you ever been employed with us before?

Are you currently employed?

May we contact your present employer?

Applying for?

Are you currently on “lay-off” status and subject to recall?

Can you travel if a job requires it?

Have you ever been convicted of indecency with a person or family?

Are you willing to take a drug screen test?

Texas Health & Human Services Form 2912

Texas Health & Human Services requires submittal of Pre-Employment Affidavit form 2912 in order to be considered for employment at certain childcare operations. Please right-click on the button below and use the "Save link as" command to download the file to your desktop. Afterwards, click on the link to the Health & Human Services website for directions on opening the form. Once the form has been completed, send it via email to hmahan@txgbr.org.

*If you have any questions or problems, you can contact Heather Mahan at the email link above or call 806-747-3187.

Pre-Employment Affidavit Form 2912 (Right Click Here)

Texas Health & Human Services Form 2912 Instructions

Education

Name & Location of High School *

Last Year Completed *

Dates Attended *

Degree/Diploma Received? *

Name & Location of College

Last Year Completed

Dates Attended

Degree/Diploma Received?

Name & Location of College

Last Year Completed

Dates Attended

Degree/Diploma Received?

Other

Last Year Completed

Dates Attended

Degree/Diploma Received?

Other Qualifications: Summarize related skills and qualifications acquired from work, school, and volunteer experiences.

Activities (Religious, Civic, Athletic, Hobbies, etc.)

Specialized Skills

If other...

State any additional information you feel may be helpful to us in considering your application.

References

*Required* - Include one (1) relative and three (3) non-related references.

Name *

Address

Phone Number *

Related to you?

Relationship? *

How Long? *

Name *

Address

Phone Number *

Related to you?

Relationship? *

How Long? *

Name *

Address

Phone Number *

Related to you?

Relationship? *

How Long? *

Name *

Address

Phone Number *

Related to you?

Relationship? *

How Long? *

Employment History

*Required* - You must account for the last five (5) years of employment and include the name of your employer, not just the name of your supervisor. Location and phone number of employer must also be included for each entry.

Start with present or last job.

Employer *

Address

Telephone Number(s) *

Job Title *

Supervisor *

Reason For Leaving? *

Dates Employed From - To *

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason For Leaving?

Dates Employed From - To

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason For Leaving?

Dates Employed From - To

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason For Leaving?

Dates Employed From - To

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

Employer

Address

Telephone Number(s)

Job Title

Supervisor

Reason For Leaving?

Dates Employed From - To

Hourly Rate/Salary Starting

Hourly Rate/Salary Ending

Work Performed

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. According to Section 1100.3 Appendix V, of Texas Minimum Standard of Child Placing Agencies; “No one who has been convicted within the preceding ten years of any felony classified as an offense against the person or family, or of public indecency or of violation of the Texas Controlled Substances Act, or any misdemeanor classified as an offense against the person or family or a public indecency, may serve as a foster parent or as an employee in an agency home unless the Director of Licensing has ruled that proof of rehabilitation has been established”. In order for the Texas Boys Ranch to meet this requirement, will you please sign the following statement? “I have not been convicted within the preceding ten years of any felony or misdemeanor as classified in the above statement." In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

e-Signature of Applicant *

Today's Date *

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***Once you click the SUBMIT button scroll up to make sure the application was actually submitted and that there were no errors or omissions***

Job Application

Texas Health & Human Services Form 2912

Education

References

Employment History