Date Of Interview
Name
How did you hear about us:
Do you have any relatives or friends working with us now or in the past?
What in your background qualifies you for this job?
What relevant experience do you have to perform the job duties and responsibilities you are seeking with our Agency?_
What would you describe as your strengths?
What would you describe as your weaknesses? _
What is the main reason, or what are the reasons, for you leaving your current job?
Do you need any special accommodation in order to perform your job responsibilities with our Agency?
Signature of authorized Agency representative conducting interview.
Full Name
Date of Birth
Social Security Number
Physical Address
City
State
Zip Code
Applicant Name (last, first, middle)
Email Address
Current Address
City, State, Zip
Home Phone
Cell Phone
Name/ Address of next of Kin
Position Applying For:
Salary Requirements
Date Available:
High School
Graduated
Degree
College
Graduated
Degree
Other
From
To
Graduated
Degree
List professional licenses you possess. Indicate type {i.e., license, certification, registration, etc.), number, and issuing state:
List any memberships in professional organizations, honors, or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law:
Name:
List languages spoken other than English:
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc.:
Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient.
Company Name
Complete Address including city, state, zip
Phone Number
Supervisor's Name
Date Started
Date Left
Reason for Leaving
Name
Describe your job title, responsibilities, and accomplishments:
Company Name
Complete Address including city, state, zip
Phone Number
Supervisor's Name
Date Started
Date Left
Reason for Leaving
Describe your job title, responsibilities, and accomplishments:
Personal References - Name, Phone, Relationship:
Emergency Contact
Relationship:
Phone
Address
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, if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list 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/ 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.
Date
CURRENT CPR CARD
DRIVER'S LICENCE
SOCIAL SECURITY CARD
STATE OF TEXAS NURSING LICENCE
TB/CHEST XRAY
HEP
VACCINE
PROOF OF CITIZENSIDP /RESIDENCY/ WORK ELIGIBILITY
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