* = Required Information

It is this agency's policy to provide equal employment opportunities without regard to age, race, color, religion, military gender preference, sex, marital status, national origin, or disability.

Present Address:
Yes No
Full Time Part Time Part Time Per Visit Pool
Day Night Evening Weekend
Yes No
Yes No
Yes No
Yes No
Educational History
Type of School: High School
9 10 11 12

Type of School: College
1 2 3 4

Type of School: College
1 2 3 4

Type of School: Other
Last Year Attended
Work History
List all of your work experience beginning with the most recent job.
Full Time Part Time Per Visit
Yes No

Full Time Part Time Per Visit
Yes No

Full Time Part Time Per Visit
Yes No
PERSONAL REFERENCES:


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 investigative 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 am an 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 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 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-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.


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