Application for Emergence Health Network Board

Please fill out this form and submit to complete the application process

PURSUANT TO TEXAS GOVERNMENT CODE, SEC. 522.021. I ELECT THAT MY HOME ADDRESS & TELEPHONE NUMBER (CHECK ONE): MAY BE RELEASED / SHALL NOT BE RELEASED TO THE PUBLIC UPON REQUEST UNDER THE TEXAS OPEN RECORDS ACT. FAILURE TO MAKE A DESIGNATION RESULTS IN INFORMATION BEING AVAILABLE FOR PUBLIC ACCESS.

Length of Residency in El Paso County

Place of Employment

Business Address

Telephone

Fax number

Professional Background

Educational Background

Three (3) personal or professional references not related to you:

Name

Phone

Years Known

Name

Phone

Years Known

Name

Phone

Years Known

Previous volunteer organization
and/or community service

Are you an elected officer, county employee, county affiliate, or employed as a lobbyist? Yes / No

If so, please specify

Signature

Date

BACKGROUND INVESTIGATION AUTHORIZATION FORM RELEASE OF CONFIDENTIAL INFORMATION Dear Applicant: The County of El Paso conducts background investigations on applicants in various departments. This effort is part of the selection process and requires your authorization. By signing this document you acknowledge that you are voluntarily granting permission to the County of El Paso to conduct a background check and you authorize relevant parties to release confidential information. The information will remain confidential and will not be disclosed.
I,, further hereby authorize the County of El Paso Human Resources Department to obtain all confidential records and information pertaining to a complete background investigation. This may include items such as (but not limited to): personal references, work references, Police Records, Sheriff Records, Driving Record, and any open record request.
Full Legal Name		Maiden Name (If Applicable)
Street Address		City/State/Zip Code
Social Security Number		Driver’s License Number/State
Date of Birth		Email
List the cities and states in which you have lived in the past 10 years.
1.		2.
3.		4.
5.		6.
Signature of Applicant:

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Application for Emergence Health Network Board