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Applicant Name *

First

Middle

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Position Applying For *

Checkboxes *

Part Time
Pool
Evening
W/E

If you are not a US Citizen, do you have the legal right to remain permanently in the US? *

Salary Requirements *

Date Available *

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? *

Educational History

Name & Location of High School *

Years Attended High School *

Graduated? *

Graduated

Degree *

Name & Location of College

Years Attended

Graduated?

Graduated

Degree

Name & Location of College

Years Attended

Graduated?

Graduated?

Degree

Other

Years Attended

Graduated?

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 race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law: *

List languages spoken other than English: *

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc: *

Work History

Company Name *

Date Started *

Date Left *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Type of Business *

Full Time
Part Time
Per Visit

Reason for leaving *

Supervisor's Name *

Ok to Contact Supervisor *

Describe your job title, responsibilities and accomplishments: *

Company Name

Date Started

Date Left

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Type of Business

Full Time
Part Time
Per Visit

Reason for leaving

Supervisor's Name

Ok to Contact Supervisor

Describe your job title, responsibilities and accomplishments:

Professional References

Professional Reference Name 1 *

First

Last

Professional Reference Phone 1 *

Professional Reference Name 2 *

First

Last

Professional Reference Phone 2 *

Professional Reference Name 3 *

First

Last

Professional Reference Phone 3 *

Please Review & Sign

Emergency Contact *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Relationship *

Phone *

Out of state contact, if possible

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

Phone

Upload Your Resume *

Click or drag a file to this area to upload.

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the Agency 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 Agency 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 and agree that if I am offered employment by the Agency, my employment will be for no definite term and that either I, or the Agency 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 Agency. *

I understand, if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform 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 HHS-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 Health and Human Services (HHS) 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 HHS-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. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment. *

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 *

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Educational History

Work History

Professional References

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