Employment (Come Work With Us) Form

APPLICANT NOTE: This application form is for use in evaluating your suitability for employment. It is not an employment contract. Please answer all appropriate questions completely and to the best of your ability. False or misleading statements are grounds for refusal or termination of employment and benefits. Federal law provides penalties for false statements on documents related to U.S. employment eligibility. The company reserves the right to determine an applicant’s eligibility for employment or termination of employment while governed by state and federal statutes regarding equality without discrimination of sex, creed, race, natural origin, religious preference or disability. Reasonable accommodation may be available to persons otherwise able to fulfill job responsibilities.

For which position are you applying?

Professional License No.(if applicable)

Expiration Date:

What date can you start?

What category would you prefer?

Full Time

Part Time

Temporary

For which schedules are you available?

Weekdays

Weekends

Evenings

Overtime

Other

Please check the highest grade completed.

16+

List any job-related military training, experience or related courses of study:

Most Recent Employer

Street Address

City, State, Zip

Telephone

Supervisor

May we contact?

Dates Employed

Salary/Pay Rate

Position/Duties

Employer

Street Address

City, State, Zip

Telephone

Supervisor

May we contact?

Dates Employed

Salary/Pay Rate

Position/Duties

Employer

Street Address

City, State, Zip

Telephone

Supervisor

May we contact?

Dates Employed

Salary/Pay Rate

Position/Duties

In which states have you lived in the past seven years?

Have you used any names or Social Security numbers other than those on page one?

Yes

If yes, please list:

Have you ever been convicted, fined, imprisoned, placed on probation or given a suspended sentence by any court, including court martial, or have you forfeited bail in connection with any offense? Do not include: (1) juvenile offenses if the record has subsequently been sealed by court order; (2) traffic violations unless an issuance of a warrant resulted.

Yes

Criminal convictions do not necessarily bar the applicant from employment. If yes, give the following information for each offense:

OFFENSE & DATE

CITY/STATE

SENTENCE AND/OR DISPOSITION

Include only individuals familiar with your work ability. Do not include relatives.

(combination of education, experience and other personal abilities you feel make you qualified for the position):

I am familiar with the mental and physical requirements of the job for which I am applying.
I certify that I am able to perform the tasks required (with or without accommodation) in the job for which I am applying.
I request the following accommodation to explain, demonstrate or continue the employment application process:

CERTIFICATION AND RELEASE: I certify that I have read and understand the Applicant Note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and its agents, to verify any of this information including, but not limited to, criminal history, Employee Misconduct Registry, and Nurse Aide Registry I understand the company will not employ an unlicensed person/volunteer with a barred conviction as defined in Texas Health and Safety Code chapter 250 or one contraindicated and will not employ/use an unlicensed person listed as unemployable on the Nurse Aide Registry or Employee Misconduct Registry. I release all persons, schools, companies and law enforcement authorities from any liabilities for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs before and during employment. I understand the Company does not require Pre/employment drug screening but reserves the right to perform screenings as needed.

The Agency is an equal employment opportunity employer dedicated to an employment policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability or national origin.

This application will remain active for 45 days. If you desire continued consideration for employment, you may reapply after that time.