Employment Application

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This field is for validation purposes and should be left unchanged.

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

Personal Information

Last Name

First Name

Middle Name

Date

MM slash DD slash YYYY

Street Address

Home Phone

City, State, Zip Code

Business Phone

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

Yes

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes

How did you learn of our organization?

Online Ad

Agency employee

Other

Are you willing to work

Evenings?

Weekends?

Position applying for

Upload Resume

Max. file size: 512 MB.

ID Social Security Card

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

2. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

3. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

4. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

5. Company Name

Telephone

Address

City, State, Zip Code

Dates of Employment

From

MM slash DD slash YYYY

Starting Pay

Job Title and describe your work

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes

If yes, what was your name?

Are you currently employed?

Yes

Do you have reliable transportation?

Yes

Professional References

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

Address

General

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full

Are you capable of performing the job set forth in the job description?

Yes

If you answered No, which job requirement can you not meet?

Credentials/specialized skills & qualifications/equipment operated

List all states in which licensed giving registration and expiration date. Summarize special jobrelated skills and qualification acquired from employment or other experience.

Please read all statements below before signing this application

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Date

MM slash DD slash YYYY

Signature

(1) Applicant Reference Check

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Applicant Name

Date of Application:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

Applicant’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay: (weekly/biweekly/salary)

Additional comments (training/skills)

Reference check performed by

(2) Applicant Reference Check

Applicant Name

Date of Application:

MM slash DD slash YYYY

Previous Employer

Contact Person

Address

Phone

Applicant’s Signature

Date

MM slash DD slash YYYY

To be completed by previous employer:

Date of employment:

From

MM slash DD slash YYYY

Position Held

Would you rehire this individual?

Yes

Responsibilities

Reason for Leaving

Rate of Pay: (weekly/biweekly/salary)

Additional comments (training/skills)

Reference check performed by

Employee Emergency Contact Information

Employee Name

Current Address

Home Phone

Cell Phone

*In case of emergency, please contact:

Name

Phone

Relationship

Address

*Please notify this Agency immediately if any of the emergency contact information changes.

Hepatitis Vaccine Requirement

acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself.

It is my decision to:

Request that I receive the Hepatitis vaccine

Refuse the Hepatitis vaccine and HOLD HARMLESS THE AGENCY. I understand that by declining the vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to me.

Provide written proof of immunity (attach)

Provide written proof of previous vaccination (attach)

Provide written proof of medical contraindication (attach)

Attach Files

Drop files here or

Max. file size: 512 MB.

Signature

Date

MM slash DD slash YYYY

Application for Employment

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 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 termination 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 that if I have direct patient/client contact the Agency will perform a background check, including criminal history check (if applicable), OIG LEIE 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 / enrollment or admissions 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 slash DD slash YYYY

FOR OFFICE USE ONLY	☐ Interview(s)	☐ References Checked	If Hired:
			Position: Salary:	Start Date: ☐ Full time ☐ Part time ☐ Per visit

Employment Application

Personal Information

Education

College

Vo-Tech or Trade

High School

Other

Employment

Professional References

General

Credentials/specialized skills & qualifications/equipment operated

Please read all statements below before signing this application

(1) Applicant Reference Check

(2) Applicant Reference Check

Employee Emergency Contact Information

Hepatitis Vaccine Requirement

Application for Employment

Emergency line

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