ORDER ND. 19853 APPROVAL OF THE HIRING OF LOUIS LOPEZ IN THE KERB COUNTY ROAD & BRIDGE DEPARTMENT On this the 27th day of September 1990, upon motion made by Commissioner Ray, seconded by Commissioner Ho.lekamp, the Court unanimously approved the hiring of Louis Lopez in the Road & Bridge Department, effective October 1, 1990 at Pay Group 12, Step 3, $14, 604.00 annually, S1, 216. 97 monthly and $608.49 semi-monthly. DATE: `~ 2 ? ~D TO: FROM: SUBJECT: COMMISSIONERS' COURT Person Requesting Budgetary Approval Section/Division L9'New Hire ^ Lateral Transfer EFFECTIVE: _!o~! 90 _ Date ^ Promotion ^ Merit ^ Demotion ^ Other I wish to employ ~ o vas Person As a ~Qvi p~ ~.~ ~- 4p~iz.~-mom at /z _' 3 at a Title of Position Grade/Step salary of ~ ~`~,~~/it~ ~~a /b• 9~ •r~o, bag, s~9 ~~~ ~ = ,pro. In accordance to Order No. 18631 approved April 27, 1989, the following documents are submitted for your approval: • The actual application for employment along with any letters of recommendations; • The written physical report signed by the doctor,(CK-05) with completed evaluation form signed by department head, and; • The Workman's Compensation Inquiry report (verbal to Department Head and followed up by written request.) L a p~ -~ CK-01 COMMISSIONERS' COURT AGENDA REQUEST • PLEASE FURNISH ONE ORIGINAL AND SEVEN OPI S OF THIS REQU STAND D UM NTS TO BE REVIEWED BY THE COURT MADE BY: ~~~~ ~~~"f~~`' OFF ICE: ~'`f'~ '~^~~ /~i~~v ~~- MEETING DATE: ~~ 9d TIME PREFERRED: ~/'9 SUBJECT: (PLEASE BE SPECIFIC): ~~p~o~E ~/~~~G ~~l~w~~C ESTIMATED LENGTH OF PRESENTATION: ~~~ ~~ IF PERSONNEL MATTER -NAME OF EMPLOYEE NAME OF PERSON ADDRESSING THE COURT: Go l/ /S ~ a,~c= ~ ~7 ~'~~ ~~N~~'~E Time far submitting this request for Court to assure that the matter Is posted 1n accordance with Article 6252- 17 Is as fol lows: • Meetings held on second Monday: 12:00 P. M. previous Wednesday • Meetings held on Thursdays: 5:00 P. M. previous Thursday. If preferable, Agenda Requests may be made on office stationery with the above I n f ormat I on attached. THIS REQUEST RECEIVED BY: THIS REQUEST RECEIVED ON f. i'. All Agenda Requests will be screened by the County Judge's Office to determine 1f adequate information has been prepared for the Court's formal consideration and action at time of Court meetings. Your cooperation w111 be appreciated and contribute towards your request being addressed at the earliest opportunity. _ , D ~T Y Y ~ o,~' f o' fit Application Fol' Employment Follow instructions exactly. Fill ouL the application form completely. If items are not applicable. enter "NA". Do not leave items blank. Resumes are accepted for any additional information they contain but not in place of a completed application. Be sure to sign the application after completion. PRRSnI~IAL. T)ATA-Print neatly nr tvne• Name(Last, l;irst, Middle) _ ~ ~ Social SecurityGN~mber Current Address (PO.B~St, Apt , City, State, Zip) Home Phone (azea_code & number) Permanent Address-if different (PO.Bx, St, Apt ,City, State, Zip) Work/Day Fhone (area code & number) Tyge of Position Desired Dace Available Minimum Acceptable Salary W~or~''Status Desired Have you ever been discharged ®Full Time ^ Part-Time ^Seasonal by an employer? ^ Yes ^ No If es ex lain: If position you a applying for requires the operation of a motor vehicle, do you have a current Texas Driver's License? es ^ No License Number: Q ~ ^ O erator ^Commercial hauffeur Do you have re fives working for Kerr County? If yes, give names, relationships, and department ^ Yes O employed EDUCATIONAL RECORD HIGHEST GRADE COMPLETED ^1^2^3 ^5^6^7^8^9^ 10^ 11 ^ 12 Did you graduate from high school/GED? ^ Yes O If a degree or vocational or college credits are required to meet minimum qualifications for a position you are seekin a transcri t is re uired: Name of School Location ~ Mo. Yr. Mo. Yr. Earned Yes N De ree/Certificate of Stud Busi/Tech/Voc Schools College-University Sem. Hrs Graduated? Graduate Schools Sem. Hrs. Graduated? CK-02 An Equal Opportunity/Affirmative Action Employer F11~IPI.OYi1~tE1\'T RECORD CONTiNTiF.D P;-ar ~ cif d . List any special course work (includ. ~ ie number of hours for the classification(s) for which you are applying. Also organizations: ~~ ~~ completed), train or experience that qualifies you list memberships in relevant professional List current licenses/certificates/registrations (indicate types and dates received) N ~. Skills• List special skills and machines or office equipment . you printing graphic equipment, data processing etc) N I~ can use (adding machines, dictation equipment, Foreign Languages (List): ~ ~ Speak L.LliFair ^ Good ^ Excellent ^ Read Fair ^ Good ^ Excellent Write ^ Fair ^ Good ^ Excellent ^ Fair ^ Good ^ Excellent ^ Fair ^ Good ^Excellent ^ Fair ^ Good ^ Excellent Milit Service - A co of a report of se aration from the Armed Forces DD-214 ma be re uired: Branch ,~f ~ Dates of Service From To Are you in the Active Reserve? ^ Yes ^ No EMPLOYMENT RECORD; This information will be the official record of your employment history and must accurately reflect all significant ,duties performed. You must provide all the information requested in order for your qualifications to be evaluated properly. Add additional sheets as needed. I. Include ALL em to ment. Be in with our resent or last osition and work back to our first osition. 2. Include volunteer work ex erience• write the word "Volunteer" beside our title. 3. List se aratel each osition held with the same em to er, includin militar service. 4. Give name listed on a roll records, if different from current name. Job T~it~l/e ~/'~ 1 ~ E' Y From (mo/ ~a~y/yr) Through (mo/day/yr) rJ 7 ~ Final Salary $ ~ , .3~ Cr~~f1~. Name of Or ani 'on ~ Address (PO.Bx, St, Apt ,City, Stat ip) ~ Phone (area code & number) - ~1 Futl- Part -Time If art-time a roximate nu ~ ber of hours cr week: Name of Supervisor ~ I/1'l Title of Supervisor Number and job types of employees supervised by you, if any (e.g. 3 managers, 2 technicians, 2 clerks): Reason for Leaving Describe the duties of our osition in order of im ortance: EiYIPLOYMENT RECORD ~ ~NTINUED Job Tie ( From (mo/da /y) Through ( o~ay/yr) t ~ r Pa e 3 of 4 nA F' al S ary $ l~ er Name of Org do . _ Address (PO.Bx, St, Apt ,City, Sta , Zi) Pho a (area code & number) Full- Part -Time If azt-time, a roximate number of hours er week: - , Name of Supervisor r Title of Supervisor Number and job types of employees supervised by you, if any (e.g. 3 managers, 2 technicians, 2 clerks): Reason for Leaving ~ ~ e C~ Describe the duties of our osition in order of im ortance: Job Title From (mo/day/yr) Through (mo/day/yr) ' Final Salary $ r Name of Organizati n ~ ~ Ad ess PO.Bx St,~Ap ,City, State, Zip) Phone (area code & number) Full- Part -Time art-time, a roximate tuber of hours er week: Name of Supervisor Tillc oC Supervisor Number and job types of employees supervised by you, if any (e.g. 3 managers, 2 technicians. 2 clerks): Reason for Leaving , Describe the duties of our osition in order of im ortance: PERSONAL DATA: '_ Do you have any existing physical or medical conditions or disabilities that would interfere with your ability to perform the job for which you have applied for? ^ y~ o If yes, please explain: _____________________-___--___--_~-_ ----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- Have you ever filed a Workers' Compensation claim? ^ y~ If yes. please explain: -----------------------------------_----- ------ ----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- • Have you ever been convicted of a crime (~ ~~ ~/ ^ Yes ^ No If yes, please explain: --________ _ ________~-___-_-_- __- ----------------------------------------------------------------------------------- Please read the following statements carefully and indicate your understanding and acceptance by signing your name in the space indicated. 1. I certify that the foregoing statements as well as those on any attachment(s) to this form arc to the best of my knowledge true and correct and that they are given of my own free will. 2. I understand that any misstatement (s) or omission(s) of material facts will constitute grounds for unfavorable consideration or dismissal from employment. 3. I understand that former employers and educational institutions may be contacted for employment and educational information. 4: I understand that Kerr County may contact my current employer for employment information before making a binding offer of employment. 5. I understand that if employed, I will serve an initial probationary period. 6. I understand that any omissions of material facts or any false information that I give to obtain past, present, or future county (KERR) benefits may result in unfavorable consideration or dismissal from employment. T. I understand that before I can be employed by the County, I must show proof of identity and U.S. citizenship or authorization to work in the U.S. (e.g. driver's license, and either a social security card or a birth certificate). ~ ~ ~~~ APPLICATION MUST BE SIGNED: _ ~ SIGNA -APPLICANT DATE EItiIPLOYIi-LENT RECORD CONTINUED Pagc 4 of ~ • Please list 3 names of individuals w ;g to provide character or profession •eferences: ' T~To..,a n aa_,...,. ~r_~__t...__ u n..~...:.._..t:_ COUNTY OF KERR APPLICATION SUPPLEMENT Please provide the following information, which will be used for internal tracking, statistical purposes and reporting to government regulatory agencies only. This page will be separated from your application, and will in no way be used in consideration of your application for employment. Kerr County is an Equal Opportunity Employer, and does not discriminate because of sex, age, race, color, disability, national origin, religion or sexual orientantio/n. Social Security Number: _~~~o~! ~~ ---- Name (Last, First, MI): ~~~ ~~L[/~__~ _ Address (Street Address) _1~~~__ 7i~~/~~~L-- J City, State, zip _L~i°rl~'~~l!~~ 1 ~Q~ __l!11a!~~ Home Phone ( ) ~1~; ~ Alternate Phone ( ) Are you a U.S. Citizen? ~°~____________________________- Please Check One: A. White Male F. Hispanic Female B. White Female C~ American IndianlAleutian Male C. Black Male H. American Indian/Aleutian Female D. ~L Black Female I. Asian/Filipino/Male E. / Hispanic Male J. Asian/Filipino/Female Disabled: Yes L ~ No {Please indicate ; he nature of your primary disability) A. Hearing Impaired D. Speech Impaired B. Mobility Impaired E. Other (Specify) C. Vision Impaired Are u currently, or have you previously been employed by the County? Yes No I If yes, when? q ~ - ° ~/u~ Department What led you to apply with the County (Check One) 1. Stopped in to check on available jobs 2. Referred by a County Employee 3. Referred by an employment agency 4. Responding to an advertised vacancy 5. Referred by T.E.C. 6. Other (Please List) Please indicate below the title of each position for which you are submitting an application today: 1. Job Title 4. 2. 5. 3. 6. CK-03 FILE SEPARATELY FROM APPLICATION ~~ i~~~' :ident Board _~~"C-e- 'rside Drive o,[ ,~c~ 78704 ~~ Please indicate whether information requested by telephone: Yes: o telephone call 9/•~ ~/9a WAIVER OF CONFIDENTIALITY tt~e intorrnation in my workers' compensation file(s) is confidential 8307, Section 9a, Revised Civil Statutes of Texas. However, I do any such right of confidentiality and both authorize and request that ion be made available to Kerr County Rnad ~. RT~Sl.C3~ 101 Spur 100 , (employer) whose address is Kerrville, TX 78028 to whom I have made application for employment. /~ Applicant's: ~ d1C,t.~+. ~Z ~ O Signature ,C. o ut s .L o ~dt Print or Type Name . DSO - 5~ - ~/Dg' Social Security Number . /oo0 3RD Sfrd~t Print or Type Street Address kc.e~e v. ~La. Tx 7~0~~ City State Zip ~.~,r~ / ~ ~ 99a Date.of Application for Employment STATE OF TEXAS X X COUNTY OF X SWORN AND SUBSCRIBED TO BEFORE ME THIS /dday o~ ~Sr~, 1940 az R v8 a ~ ./ Signature o otary Public Printed Name of Notary Public .. ~ ~ / (Seal) My Commission Expires: /D .Z 9/ f iF it ~E if iF iF iF -k ~1F -lF iF !F iF iF iF iF 3! dE !k ~IF if iF iF if iF * ~F ~F iF iF il~iF iF ~Ik ~F iF 1F iF if ~F !F iF ~F * iF iF iF aF ~F #~i i f ~F#~ f #* iFiF }fit#~•11f t3 ' This information is requested in accordance with the provisions of Article 8307, Section 9a, Revised Civil Statutes of Texas, as amended. Gerald W. Menefee, P.E. County Engineer Name of Requestor Title of Requestor R-12 (Rev. 4/84) C-3 i ~KERR COUNTY MEDICAL REPORT ~(PHYSlCIAN'S COPY) I, ,,~,C2,~tl W ,~ 1~'1 " licensed physician, h have on this date, medically examined ~,e~~e.i~ /~-- O_ find him/her to be in sound physical condition and firee fr m n' could prevent or dversely affect the performance of his her u ~ -- q ~ certify that I and a defects that Date Signature of Physician ~~ ~~~~ T,~~~ Physician's License Number KEEP THIS FOR YOUR RECORDS. KERR COUNTY MEDICAL REPORT (APPLICANTS COPY) !, ~t:~ GC> ~u.Cs-~ x'1'1 }~, a licensed physician, have on this date, medically examined find him/her to be in sound physical condition and free fr "could prevent or a~~dversel affect the per ormance of hi /her .fin a.Y~L/ i ~~._~ //7'Y,. ~~it/ l ~y physi defects that uties ~~ ~~ ~-Q~ Signature of Physician ~. ~ ~~~ Physician's License Number hereby certify that I and PLEASE GIVE THIS PORTION TO APPLICANT TO BE RETURNED TO KERB COUNTY DEPARTMENT HEAD. KERB COUNTY MEDICAL EXAMINATION REQUEST TO: Dr. Dan Bacon/Dr. Georgia Roth 1105 East Main Kerrville, Texas 78028 (512) 257-6212 PLEASE CONDUCT A PHYSICAL ON: APPLICANT: Name: Address: Phone Number: City: TYPE OF POSITION APPLYING FOR: Clerical _____»~N___~rN_ Non /Clerical f - ~____~~~_`~ Date of Time of Appointment: _~~d ~0____ Appointment .fir p° Please indicate by checking the appropriate box additional testing required: ^ X-Ray Back ^ Psycholo is Profile ^ X-Ray Cfiest ~. Other ^ Drug After medical exam is completed, please return physician's test results and Kerr County Medical Report (CK-05) to: Elected Official/Department Head 700 Main Street I