ApplicationPlease apply below and we’ll be in contact with you quickly! * = Required Information Position applying for Option Attendant / Caregiver HHA / CNA LVN Marketing RN SW Chaplain Volunteer Other / Office Applicant Name * Email Address * Present Address * Home Phone * Mobile Phone * Social Security Number * Are you at least 18 Years Old? * Yes No Times Available Day Start Time AM / PM End Time AM / PM Monday AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Tuesday 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Wednesday 09:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Thursday 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Friday 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Saturday 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Sunday 09:00 10:00 11:00 12:00 01:00 02:00 03:00 03:00 04:00 05:00 06:00 07:00 08:00 AM PM 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 AM PM Salary Requirements Date Available MM DD YYYY If you are not a US Citizen, do you have 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 Are you presently charged with any violation of the law other than traffic violation? Yes No Educational History High School Name & Location of School Circle Last Year Attended 9 10 11 12 Graduated Degree College Name & Location of School Circle Last Year Attended 1 2 3 4 Graduated Degree Other Name & Location of School Last Year Attended (From) MM DD YYYY Last Year Attended (To) MM DD YYYY Graduated Degree 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, 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 science, typing speed, etc: In case of an emergency notify Relationship Out of state contact, if possible Relationship NAME Work History (1) Company Name Complete Address Phone Number Supervisor's Name Date Started MM DD YYYY Date Left MM DD YYYY Reason for leaving OK to Contact Supervisor Yes No Describe your job title, responsibilities and accomplishments (2) Company Name Complete Address Phone Number Supervisor's Name Date Started MM DD YYYY Date Left MM DD YYYY Reason for leaving OK to Contact Supervisor Yes No Describe your job title, responsibilities and accomplishments (3) Company Name Complete Address Phone Number Supervisor's Name Date Started MM DD YYYY Date Left MM DD YYYY Reason for leaving OK to Contact Supervisor Yes No Describe your job title, responsibilities and accomplishments NAME 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 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 investigativve 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 have direct patient contact or contact with patient records, that the agency will perform a criminal history check per Federal Regulation, as well as check of the Nurse Aide Registry and Employee Misconduct Registry for unlicensed employees. 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 investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act 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-requlated 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 commited 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 MM DD YYYY Upload File * FileField; MaxSize=10000kb; Multiple Thank you!
