VR1850 Employment Data Sheet - Texas



Texas Workforce CommissionVocational Rehabilitation ServicesEmployment Data Sheet FORMTEXT ?Demographic Information FORMTEXT ?Instructions: Type the information below: FORMTEXT ?Date completed: FORMTEXT ?????Date most recently updated: FORMTEXT ????? First name: FORMTEXT ?????Middle name: FORMTEXT ?????Last name: FORMTEXT ?????Date of birth: FORMTEXT ?????Street address: FORMTEXT ?????Apartment number or PO box number (if any): FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Mailing address, if different from the address listed above. FORMTEXT ?Street address: FORMTEXT ?????Apartment number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Phone 1: FORMTEXT ?????Phone 2: FORMTEXT ?????Phone 3: FORMTEXT ?????Email: FORMTEXT ?????Other contact method: FORMTEXT ?????Types of driver’s licenses: FORMTEXT ? FORMCHECKBOX Class C FORMCHECKBOX Commercial FORMCHECKBOX Restricted FORMCHECKBOX NoneDriver’s License Number or State ID Number: FORMTEXT ?????Languages spoken: FORMTEXT ? FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX Other: FORMTEXT ?????Describe reasons for gaps in work or volunteer history FORMTEXT ?????Arrest and Conviction History FORMTEXT ?Any arrest(s) or convictions of a criminal offense(s) you have, that were gained at any age, may interfere with obtaining employment. Disposition(s)requirements such as payments, probation, and registration requirements can impact employment. FORMTEXT ? FORMTEXT ? FORMCHECKBOX No history of arrest(s) or convictions of a criminal offense(s) gained at any ageOffense/Charge: FORMTEXT ?????Felony Charge FORMCHECKBOX Yes FORMCHECKBOX NoDate: FORMTEXT ?????Location: FORMTEXT ?????Disposition (payments, probation, parole, registration): FORMTEXT ?????Offense/Charge: FORMTEXT ?????Felony Charge FORMTEXT ? FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDate: FORMTEXT ?????Location: FORMTEXT ?????Disposition (payments, probation, registration): FORMTEXT ?????Offense/Charge: FORMTEXT ?????Felony Charge FORMTEXT ? FORMCHECKBOX Yes FORMCHECKBOX NoDate: FORMTEXT ?????Location: FORMTEXT ?????Disposition (payments, probation, registration): FORMTEXT ?????Paid Work History FORMTEXT ?Paid work history includes positions you held or are holding that you earn a wage. FORMCHECKBOX No work history to reportEmployer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider re-hiring you? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerialNumber of employees supervised: FORMTEXT ?????Type of employment: FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider re-hiring you? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerialNumber of employees supervised: FORMTEXT ?????Type of employment: FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider re-hiring you? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerialNumber of employees supervised: FORMTEXT ?????Type of employment: FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider re-hiring you? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerialNumber of employees supervised: FORMTEXT ?????Type of employment: FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Employer: FORMTEXT ?????Job title: FORMTEXT ?????Start date: FORMTEXT ?????End date: FORMTEXT ?????Earnings: FORMTEXT ?????Average Number of hours worked per week: FORMTEXT ?????Street address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Reason for leaving: FORMTEXT ?????Do you think this employer will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think that this employer would consider re-hiring you? FORMCHECKBOX Yes FORMCHECKBOX NoRoles: FORMCHECKBOX Technical FORMCHECKBOX Non-managerial FORMCHECKBOX Supervisory or managerialNumber of employees supervised: FORMTEXT ?????Type of employment: FORMCHECKBOX Full-time FORMCHECKBOX Part-time FORMCHECKBOX Temporary or project FORMCHECKBOX Summer FORMCHECKBOX Contract FORMCHECKBOX Other: FORMTEXT ?????Average hours worked: FORMTEXT ?????Describe job duties: FORMTEXT ?????Volunteer History FORMTEXT ?Volunteer positions are unpaid positions held such as church positions,community service assignments, trustee positions, etc. FORMTEXT ? FORMCHECKBOX No volunteer history to reportAgency: FORMTEXT ?????Volunteer title: FORMTEXT ?????Start Date: FORMTEXT ?????End date: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Number of hours volunteered: FORMTEXT ?????Reason for leaving: FORMTEXT ?????May we contact this agency to gain information about your volunteer work? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency could and would consider hiring you as an employee? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe volunteer duties: FORMTEXT ?????Agency: FORMTEXT ?????Volunteer title: FORMTEXT ?????Start Date: FORMTEXT ?????End date: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Number of hours volunteered: FORMTEXT ?????Reason for leaving: FORMTEXT ?????May we contact this agency to gain information about your volunteer work? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency could and would consider hiring you as an employee? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe volunteer duties: FORMTEXT ?????Agency: FORMTEXT ?????Volunteer title: FORMTEXT ?????Start Date: FORMTEXT ?????End date: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Supervisor’s name: FORMTEXT ?????Phone: FORMTEXT ?????Supervisor’s email: FORMTEXT ?????Other contact method: FORMTEXT ?????Number of hours volunteered: FORMTEXT ?????Reason for leaving: FORMTEXT ?????May we contact this agency to gain information about your volunteer work? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this agency could and would consider hiring you as an employee? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe volunteer duties: FORMTEXT ?????Reference Details FORMTEXT ?Employment references are individuals that serve as the point of contact for employers to verify or ask questions about a potential your background, work experience, or work ethic. FORMTEXT ? FORMTEXT ?Name: FORMTEXT ?????How long have you known the reference? FORMTEXT ?????Reference’s job title: FORMTEXT ?????Relationship to reference: FORMTEXT ?????Company name, when applicable: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????May we contact this reference to gain information about you? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this person will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoName: FORMTEXT ?????How long have you known the reference? FORMTEXT ?????Reference’s job title: FORMTEXT ?????Relationship to reference: FORMTEXT ?????Company name, when applicable: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????May we contact this reference to gain information about you? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this person will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoName: FORMTEXT ?????How long have you known the reference? FORMTEXT ?????Reference’s job title: FORMTEXT ?????Relationship to reference: FORMTEXT ?????Company name, when applicable: FORMTEXT ?????Phone: FORMTEXT ?????Email: FORMTEXT ?????Address: FORMTEXT ?????Suite number or PO box number: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????May we contact this reference to gain information about you? FORMCHECKBOX Yes FORMCHECKBOX NoDo you think this person will give you a good reference? FORMCHECKBOX Yes FORMCHECKBOX NoEmployment Skills FORMTEXT ?Employment skills are abilities gained through training, experience, and achievements and include hard and soft skills that make you a desirable candidate to an employer. FORMTEXT ? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Career Objectives FORMTEXT ?Career objectives are short statements that describe the type of employment you desire and how your skills make you a good fit. FORMTEXT ?Record career objective(s) below. FORMTEXT ?????Training History Information FORMTEXT ?Training history information is a record of courses or programs you have completed to gain skills necessary to enter or advance in your employment. FORMTEXT ? FORMCHECKBOX No training history to reportInstitution name: FORMTEXT ?????Course title: FORMTEXT ?????Total hours: FORMTEXT ?????Course status: FORMCHECKBOX Completed FORMCHECKBOX Enrolled FORMCHECKBOX IncompleteCourse description: FORMTEXT ?????Institution name: FORMTEXT ?????Course title: FORMTEXT ?????Total hours: FORMTEXT ?????Course status: FORMCHECKBOX Completed FORMCHECKBOX Enrolled FORMCHECKBOX IncompleteCourse description: FORMTEXT ?????Institution name: FORMTEXT ?????Course title: FORMTEXT ?????Total hours: FORMTEXT ?????Course status: FORMCHECKBOX Completed FORMCHECKBOX Enrolled FORMCHECKBOX IncompleteCourse description: FORMTEXT ?????Occupational License or Certification Information FORMTEXT ?Occupational licensure is a form of government regulation requiring a license to pursue a particular profession or vocation. FORMTEXT ? Certification is a third-party verification of an individual's level of knowledge or proficiency in a certain industry or profession. FORMTEXT ? Registration is defined as the recognition of successful completion of mandated requirements for the practice of a particular profession. FORMTEXT ? FORMCHECKBOX No occupational license or certification information to report.Type: FORMCHECKBOX Certification FORMCHECKBOX License FORMCHECKBOX Registration FORMCHECKBOX Other (specify): FORMTEXT ?????Issuer: FORMTEXT ?????Title: FORMTEXT ?????Number issued: FORMTEXT ?????County: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Date issued: FORMTEXT ?????Recertification date: FORMTEXT ?????Expiration date: FORMTEXT ?????Type: FORMCHECKBOX Certification FORMCHECKBOX License FORMCHECKBOX Registration FORMCHECKBOX Other (specify): FORMTEXT ?????Issuer: FORMTEXT ?????Title: FORMTEXT ?????Number issued: FORMTEXT ?????County: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Date issued: FORMTEXT ?????Recertification date: FORMTEXT ?????Expiration date: FORMTEXT ?????Type: FORMCHECKBOX Certification FORMCHECKBOX License FORMCHECKBOX Registration FORMCHECKBOX Other (specify): FORMTEXT ?????Issuer: FORMTEXT ?????Title: FORMTEXT ?????Number issued: FORMTEXT ?????County: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Date issued: FORMTEXT ?????Recertification date: FORMTEXT ?????Expiration date: FORMTEXT ?????High School and GED Information FORMTEXT ?A high school diploma is awarded upon high school graduation. FORMTEXT ? A General Education Development (GED) credential is offered as an alternative qualification for those who did not successfully earn a high school diploma. FORMTEXT ?Name of school district: FORMTEXT ?????High school name: FORMTEXT ?????Phone: FORMTEXT ?????Address: FORMTEXT ?????State: FORMTEXT ????? County: FORMTEXT ?????ZIP code: FORMTEXT ?????Date started high school: FORMTEXT ?????Date graduated: FORMTEXT ?????Date of GED: FORMTEXT ?????College Education History FORMTEXT ?Institution of higher education (college, university) where associate, bachelor, master, doctorate degrees can be earned. FORMTEXT ? Not technical or professional training. FORMTEXT ? ? FORMCHECKBOX No college education information to report.Name of school: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Dates attended: FORMTEXT ?????Program completed? FORMCHECKBOX Yes FORMCHECKBOX NoMajor and minor areas of study: FORMTEXT ?????Name of school: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Dates attended: FORMTEXT ?????Program completed? FORMCHECKBOX Yes FORMCHECKBOX NoMajor and minor areas of study: FORMTEXT ?????Name of school: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Dates attended: FORMTEXT ?????Program completed? FORMCHECKBOX Yes FORMCHECKBOX NoMajor and minor areas of study: FORMTEXT ?????Name of school: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Dates attended: FORMTEXT ?????Program completed? FORMCHECKBOX Yes FORMCHECKBOX NoMajor and minor areas of study: FORMTEXT ?????Comments, if any: FORMTEXT ????? ................
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