Digestive Health Associated of Texas - Employment Application

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.

I understand that neither this document nor any offer of employment from the employer constitutes an employment contract.

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.

In connection with my consideration for employment or reassignment at Digestive Health, I understand that this prospective employer or its agent, Dale Simpson & Associates, Inc., may obtain or assemble a consumer report/investigative report about me related to my character, work habits, performance, along with reasons for termination of past employment. I understand that information from public and private sources may be requested. These sources may contain records regarding my driving record, worker's compensation injuries, court records, credit credentials, education, and references. I realize that according to the Fair Credit Reporting Act (FCRA), I am entitled to know if I am being denied employment by this prospective employer because of information obtained from a consumer reporting agency. If so, I will be notified and given the information source or reporting agency's name and address. I understand that I am being given a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. Section 1681-1681u. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.

Signature of Applicant: Date of Birth: Last 4 of Social Security:
Typing your first and last name acts as your digital signature Please format: mm/dd/yyyy

E-mail Address:

Attach Resume/CV to Form

If employed and under 18 years of age, can you furnish a work permit?	Yes	No
Have you filed an application with this company before?	Yes	No
If yes, give date:
Have you ever been employed with this company before?	Yes	No
If yes, give date:
Are you currently employed?	Yes	No
May we contact your present employer?	Yes	No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?	Yes	No
On what date would you be available for work?
When are you available to work? Full Time Part Time PRN Temporary
Have you been convicted of a felony?	Yes	No
If yes, please explain:

Elmentary School
School Name:		Years Completed:
High School
School Name:		Years Completed:

College/University
School Name:	Years Completed:	Diploma/Degree:	Yes	No
Course of Study:

Graduate/Professional
School Name:	Years Completed:	Diploma/Degree:	Yes	No
Course of Study:

Provide the name, address and telephone numbers of two references who are previous employers.
1.)	Name:	Telephone:
	Address:

2.)	Name:	Telephone:
	Address:

Employer:	Telephone:	Start Date:	End Date:
Address:	City:	State:	Zip Code:
Job Title:	Supervisor:	Starting Rate:	Ending Rate:
Work Performed:
Reason for Leaving:

Were you referred by another DHM employee?		Yes No
Name of referrer:

This employer is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites applicants to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable law, executive orders and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify a specific individual.
Gender (check one)
	Male	Female	I elect not to provide this information.
Race/Ethnicity (check one)
	White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
	Black (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa.
	Hispanic or Latino A person of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin, regardless of race.
	Asian (Not Hispanic or Latino)
	Native Hawaiian or other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent or the Pacific Islands. This area includes, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands and Samoa.
	American Indian or Alaska Native (Not Hispanic or Latino) A person having origins in any of the original peoples of North America and South America, and who maintain cultural identification through tribal affiliation or community recognition attachment.
	Two or More Races All persons who identify with more than one of the above races.
	I elect not to provide this information.