Application For Employment

Page 1 of 5

Please read before filling out this application.

The Hughen Center, Inc. does not discriminate in firing or employment on the basis of race, color, religious creed, national origin, sex, ancestry, mental or physical disability, marital status, or on the basis of age or veteran status.

This application will be given every consideration, but its receipt does not imply that the applicant will be employed.

In processing this employment application, The Hughen Center, Inc. will conduct a Criminal Background Check for any felony or misdemeanor classified as an offense against persons or family, or of public indecency, or violation of the Texas Controlled Substance Act.

You have the right to request that we disclose to you the nature and scope of the investigation requested. Such a request must be made in writing to the Personnel Department of this Agency within a reasonable time after you complete this application.

Applicant Information

First Name

Middle Name

Last Name

Telephone Number

Email Address

Social Security Number

Position Applying For

Salary Requirements

Application For Employment

Page 2 of 5

Criminal Background Check

According to the laws of the State of Texas, you must pass a criminal background check in order to work or volunteer in a child-care facility. Please list ALL arrests, deferred adjudications, convictions or altercations with law enforcement (if none, write NONE):

Incident 1

Incident 2

Incident 3

Incident 4

I understand that, if employed, any misstatement
|or omission of fact on this criminal background
check shall be cause for dismissal

Date

Application For Employment

Page 3 of 5

Education

High School or Preparatory

Name

City-State

Degree

Years Completed

Major Course or Subject

Trade, Business Or Correspondence School

Name

City-State

Degree

Years Completed

Major Course or Subject

College

Name

City-State

Degree

Years Completed

Major Course or Subject

Personal References

Name

Relationship

Daytime Phone

Name

Relationship

Daytime Phone

Name

Relationship

Daytime Phone

Application For Employment

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Employment History

Beginning with present or last employers, list all full-time or part-time positions.

Employer #1

Company Name

Phone

Month/Year Start

Month/Year End

Starting Salary

Ending Salary

Supervisor Name

Job Title

Job Duties

Reason For Leaving

Employer #2

Company Name

Phone

Month/Year Start

Month/Year End

Starting Salary

Ending Salary

Supervisor Name

Job Title

Job Duties

Reason For Leaving

Employer #3

Company Name

Phone

Month/Year Start

Month/Year End

Starting Salary

Ending Salary

Supervisor Name

Job Title

Job Duties

Reason For Leaving

Application For Employment

Page 5 of 5

Please read before signing:

If you have any questions regarding this statement, please ask the employment interviewer before signing.

If The Hughen Center, Inc. employs me, I understand that my employment can be terminated by me or by the agency with or without cause and without prior notice. All policy statements of The Hughen Center, Inc., including policy and procedure manuals and employee handbooks, are strictly internal guidelines issued at the sole discretion of The Hughen Center, Inc. and do not have the effect of changing either the term or terminability of my employment.

I hereby declare that the information provided by me in this application is true, correct and complete to the best of my knowledge. I understand that if employed any misstatement or omission of fact on this application shall be cause for dismissal.

I understand that if I am offered and accept employment by the agency, such employment is conditional and subject to my completion on INS Form I-9 and my meeting the eligibility requirements set forth therein and under applicable federal law.

I UNDERSTAND THAT IF I AM OFFERED AND ACCEPT EMPLOYMENT BY THE AGENCY, SUCH EMPLOYMENT IS CONDITIONAL AND SUBJECT TO MY PASSING A TB TEST, A DRUG TEST, HAVING A CLEAR MVR, AND A CLEAR CRIMINAL BACKGROUND.

I hereby acknowledge that I have read the
above statement and understand the same.

Date