It is this agency’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.
Are you at least 18 years old?:
Position Applying For:
Shift:
If you are not a US Citizen, have you the legal right to remain permanently in the US?
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:
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?
Are you presently charged with any violation of the law other than traffic violation?
Educational History
List professional licenses you possess. Indicate type of license, number, and state of issue:
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, 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 experience, typing speed, etc:
In case of an emergency notify
Out of state contact, if possible
Work History
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient.
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 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 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 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 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 is 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.
• I understand that, per agency policy, Criminal History Checks will be performed on all applicants prior to hiring and annually, thereafter.
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.
Dated
