Employment Application

Position Desired & Qualification
Position Applied For:
Positions I Qualify For:
How did you hear about open positions at Bluebonnet Trails Community Services?*
- BTCS website: www.bbtrails.org
- Craigslist
- Facebook
- Handshake
- Indeed
- LinkedIn
- Local Newspaper
- Professional Networking
- Referred by Current Employee
- UT Steer Your Career
- Work In Texas
- Other
Referral Source:
Name of Current Employee that Referred you:
Personal Information
Name:*
First Last
Middle Name:
Email:*

Address:*
Street Address City State ZIP Code
Home Phone:
Work Phone:
Cell Phone:
Convictions:*
- No
- Yes
Conviction Description:
List any other names if different from name given on application:
Date Available for Work:
MM slash DD slash YYYY
Do you have a Valid Texas Driver's License?*
- Yes
- No
Do you have any relatives working for Bluebonnet Trails Community MHMR Center?*
- Yes
- No
If yes, list names, relationship and location where employed:
Military Service
Military Service (Dates of Service):

(A copy of a report of separation from the Armed Services may be required)
Are you a surviving spouse or orphan of a veteran?
- Yes
- No

Education Information
Graduated from High School (or completed GED)
- Yes
Name of High School:
Colleges Attended (separate with commas):
Degrees
Degree Earned Degree Date Degree Specialty
Professional Licensure/Other Degrees: Has your license or practice ever been under disciplinary action, restrictions or reviewed by a licensing/authorizing/credentialing?
- Yes
- No
If yes, please explain:
Other Degrees:
Other Type of School:
Other Training:
Foreign Languages:
Typing WPM:
Sign Language:
Related Experience:
Special Certifications:

Employers
Employer 1
Company Name:
Address:
Position/Title:
Hire Date:
MM slash DD slash YYYY
Termination Date:
MM slash DD slash YYYY
Reason for Termination or Currently Employed:
Supervisor:
Salary (Start - End):
Job Duties:
Work Phone Number:
Employer 2
Company Name:
Address:
Untitled
Hire Date:
MM slash DD slash YYYY
Termination Date:
MM slash DD slash YYYY
Supervisor:
Reason for Termination or Currently Employed:
Salary (Start - End):
Job Duties:
Work Phone Number:
Employer 3
Company Name:
Address:
Position/Title:
Hire Date:
MM slash DD slash YYYY
Termination Date:
MM slash DD slash YYYY
Supervisor:
Reason for Termination or Currently Employed:
Salary (Start - End):
Job Duties:
Work Phone Number:

Professional References
Reference 1
Name of Reference:
Relation to Reference:*
Address:
Phone:
Email
Reference 2
Name of Reference:
Relation to Reference:*
Address:
Phone:
Email:
Reference 3
Name of Reference:
Relation to Reference:*
Address:
Phone:
Email:

CONVICTIONS BARRING CONTRACTING OR EMPLOYMENT
Please read the following statements carefully and indicate your understanding and acceptance by checking the box below:
CONVICTIONS BARRING CONTRACTING
Texas Health and Safety Code, Sec. 250.006. CONVICTIONS BARRING EMPLOYMENT.
(a) A person for whom the facility or the individual employer is entitled to obtain criminal history record information may not be employed in a facility or by an individual employer if the person has been convicted of an offense listed in this subsection:
1. an offense under Chapter 19, Penal Code (criminal homicide);
2. an offense under Chapter 20, Penal Code (kidnapping and unlawful restraint);
3. an offense under Section 21.02, Penal Code (continuous sexual abuse of young child or children), or Section 21.11, Penal Code (indecency with a child);
4. an offense under Section 22.011, Penal Code (sexual assault);
5. an offense under Section 22.02, Penal Code (aggravated assault);
6. an offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
7. an offense under Section 22.041, Penal Code (abandoning or endangering child);
8. an offense under Section 22.08, Penal Code (aiding suicide);
9. an offense under Section 25.031, Penal Code (agreement to abduct from custody);
10. an offense under Section 25.08, Penal Code (sale or purchase of a child);
11. an offense under Section 28.02, Penal Code (arson);
12. an offense under Section 29.02, Penal Code (robbery);
13. an offense under Section 29.03, Penal Code (aggravated robbery);
14. an offense under Section 21.08, Penal Code (indecent exposure);
15. an offense under Section 21.12, Penal Code (improper relationship between educator and student);
16. an offense under Section 21.15, Penal Code (improper photography or visual recording);
17. an offense under Section 22.05, Penal Code (deadly conduct);
18. an offense under Section 22.021, Penal Code (aggravated sexual assault);
19. an offense under Section 22.07, Penal Code (terroristic threat);
20. an offense under Section 33.021, Penal Code (online solicitation of a minor);
21. an offense under Section 34.02, Penal Code (money laundering);
22. an offense under Section 35A.02, Penal Code (Medicaid fraud);
23. an offense under Section 36.06, Penal Code (obstruction or retaliation);
24. an offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to nonlivestock animals); or
25. a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
(b) A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of:
1. an offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony;
2. an offense under Section 30.02, Penal Code (burglary);
3. an offense under Chapter 31, Penal Code (theft), that is punishable as a felony;
4. an offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;
5. an offense under Section 32.46, Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
6. an offense under Section 37.12, Penal Code (false identification as peace officer); or
7. an offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).
(c) In addition to the prohibitions on employment prescribed by Subsections (a) and (b), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:
1. of an offense under Section 30.02, Penal Code (burglary); or
2. under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.
3. For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.
The conviction of other criminal offenses may be considered a contraindication to contracting with Bluebonnet Trails Community Services.
Applicants who are listed as “revoked” in the Nurse Aide Registry, listed as “unemployable” in the Employee Misconduct Registry or on the List of Excluded Individuals and Entities for Medicaid fraud will be barred from contracting.
If you agree to abide by the terms of the above statement, check the box to indicate your agreement.*
- Agree
By submitting my application for employment with Bluebonnet Trails Community Services, I acknowledge the Center's commitment to maintaining a tobacco-free workplace.*
- Agree

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Degree Earned	Degree Date	Degree Specialty

Step 1 of 7

Position Desired & Qualification

Personal Information

Military Service

Education Information

Employers

Employer 1

Employer 2

Employer 3

Professional References

Reference 1

Reference 2

Reference 3

CONVICTIONS BARRING CONTRACTING OR EMPLOYMENT

CONVICTIONS BARRING CONTRACTING