* = 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, genetic information, sex, marital status, national origin, or disability.
Applicant Name *
 Email
Present Address
Home Phone
Mobile Phone
Social Security Number
Are You at Least 18 Years Old?
Yes No
Position Applying For:
Full Time Part Time
Part Time Per Visit Pool 		Shift
Day Night
Evening 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
- If Yes, please give date, place and nature of each such conviction
Are you presently charged with any violation of the law other than traffic violation?
Yes No
- If Yes, please give date, place and nature of each such conviction

Educational History
Type of School Name & Location of School Circle Last Year Attended Graduated Degree
High School
9 10 11 12
College
1 2 3 4
College
1 2 3 4
Other
1 2 3 4
 
List of professional licenses you posses. Indicate type of license, number and state.
 
List any membership in professional organizations, honor or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, genetic information, 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 emergency notify
 Relationship
Yes No
Out of state contact, if possible
 Relationship
Yes No

Work History
Company Name
 Complete Address Incl City/State/Zip
 Phone Number
 Supervisor's Name
Date Started

Date Left
 Type of Business
Full Time
Per Visit
Part Time

Salary
 Reason For Leaving
 OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
Company Name
 Complete Address Incl City/State/Zip
 Phone Number
 Supervisor's Name
Date Started

Date Left
 Type of Business
Full Time
Per Visit
Part Time

Salary
 Reason For Leaving
 OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
Company Name
 Complete Address Incl City/State/Zip
 Phone Number
 Supervisor's Name
Date Started

Date Left
 Type of Business
Full Time
Per Visit
Part Time

Salary
 Reason For Leaving
 OK to Contact Supervisor
Yes No
Describe your job title, responsibilities and accomplishments
 
Personal References: (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 bu 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 received 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 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 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 who 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 investigative allegations of abuse, neglect, or misappropriation, the nurse aide 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 Name
Date

Please follow-up with a phone call to 281-861-9146 to verify submission of your application.