* = Required Information

Position applying for: Nurse
Licensed Vocational Nurse
Certified Nursing Assistant
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech and Language Pathologist
Medical Social Worker
Office Staff
Duty Preference: Full Time
Part Time/per visit
Personal Information
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YesNo
Newspaper Ad
Agency employee
Other
Evenings Weekends
Education
School Name Location of School Course of Study Years of Degree Study
Diploma/College:
Vo-Tech or Trade:
High School:
Other:
Employment
List the last five years employment history, starting with the most recent employer.
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Application for Employment
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YesNo
YesNo
General
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YesNo
Application for Employment
CREDENTIALS, SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED
List all licenses you possess and the states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.
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 hereby 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.
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.
Applicant Reference Check (1)
I hereby authorize the following information to be released. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
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Applicant Reference Check (2)
I hereby authorize the following information to be released. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.
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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.
  • **It is the Agency's policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, genetic information, sex, marital status or national origin.
  • **After application evaluation, the applicant will receive a feedback from the Agency if the application has been accepted.