* = Required Information

Application for Employment
 
It is this agency's policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.
Applicant Name *
Email Address *
Present Address
City * State Zip Code
Home Phone *
Mobile Phone
Social Security No
Are You at Least 18 Years Old?
Yes No
Position Applying For
Full Time
Part Time
Part Time Per Visit
Pool
Shift
Day
Evening
Night
W/E
Salary Requirements
Date Available
If you are not a US Citizen, have you the legal right to remain permanently in the US?
Yes No
Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?
Yes No
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years? Yes No
Education History
Type of School Name and Location of School Last Year Attended Graduated Degree
High School 9101112
Yes No
College 1234
Yes No
Other FromTo
Yes No
List professional licenses you possess. Indicate type of license, number and state
List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.
List languages spoken other than English
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc
In case of an emergency
Relationship
Out of state contact, if possible
Relationship
Work History
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient.
Company Name Complete Address City/State/Zip Phone Number Supervisor's Name
Date StartedDate Left      Type of Business
Full Time
Part Time
Per Visit
Reason for leaving OK to contact Supervisor?
Yes No
Describe your job title, responsibilities and accomplishments
Company Name Complete Address City/State/Zip Phone Number Supervisor's Name
Date StartedDate Left      Type of Business
Full Time
Part Time
Per Visit
Reason for leaving OK to contact Supervisor?
Yes No
Describe your job title, responsibilities and accomplishments
Company Name Complete Address City/State/Zip Phone Number Supervisor's Name
Date StartedDate Left      Type of Business
Full Time
Part Time
Per Visit
Reason for leaving OK to contact Supervisor?
Yes No
Describe your job title, responsibilities and accomplishments
Personal References
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Please review and sign
In making application for employment
  • I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented. I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
  • I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
  • I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.
  • I understand, if I am an unlicensed person who has face-to-face patient/client contact, that the agency will perform a criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in DADS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides ho are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Department of Aging and Disability Services (DADS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse ideas and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aid may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS - regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable.
Release:     I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.
Applicant Signature* Date