Certified Nurse Associate -

Name

Address

All prospective employees will receive consideration without discrimination because of race, color, sex, age, natural origin, or handicap. All information provided here will be kept confidential.

PERSONAL

Date

Street Address

Home Phone

City, State, Zip

Business Phone

Social Security Number

Date of Birth

Emergency Contact (person not living with you)

Phone

Have you ever applied for employment with the agency?

Yes No

How many hours a week are you available for work?

Minimum Maximum

When will you be available for work?

Are you legally eligible for employment in the United States?

Yes No

How did you find this Agency?

Newspaper Ad Agency Employee Other

Are you willing to work

Evenings? Weekends?

Position applying for

Provider Home Health Aide

EDUCATION

School Name	Location	Course	Years Completed	Degree/Diploma

EMPLOYMENT HISTORY

From	Company	Business Type	Position	Phone	Reason

Duties / Responsibilities:

From	Company	Business Type	Position	Phone	Reason

Duties / Responsibilities:

Have you used another name in the past?

Yes No

If yes, what name?

Are you currently employed?

Yes No

May we contact your previous employer?

Yes No

Do you have reliable transportation?

Yes No

REFERENCES / CONTACTS

Name:	Phone:
Address:

Name:	Phone:
Address:

Name:	Phone:
Address:

GENERAL Have you been convicted of a crime in the past 5 years, barring employment in a Home and Community support services Agency?

Yes No

Conviction will not necessarily disqualify an applicant from employment. If yes, describe:

Are you capable of performing the job duties in the job description?

Yes No

If you answered No, which job requirements can you not meet?

List all 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 authorized complete investigation of all statements contained herein and herby 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 same to the Agency. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of the 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 accepted at this time.

Date

Employees’ Name

Address

[Date]

Employment Offer Notice

Dear,

This is to inform you that you have been offered a position as an attendant/provider employee for BECAL HEALTHCARE.

Minimum Base Wage Schedule:

Beginning September 1, 2013: $7.50 per hour
Beginning September 1, 2014: $7.86 per hour
Beginning September 1, 2015: $8.00 per hour
Beginning September 1, 2019: $8.11 per hour
Beginning September 1, 2023: $10.60 per hour
Beginning September 1, 2025: $13.00 per hour

The offer rate given to you is _______ per hour.

The date of your employment will commence on ____________________.

Sincerely,
[Sender Name]
[Sender Title]

NOTE: Click any underlined area to edit. For more rigid form behavior (e.g. required fields), replace the span[contenteditable] elements with input fields or a simple form.

By signing below, I acknowledge and accept pay rate.

DRIVER'S LICENSE

STATE OF TEXAS ID

SOCIAL SECURITY CARD

TB/CHEST XRAY

HEP B VACCINE

PROOF OF CITIZENSIDP /RESIDENCY/ WORK ELIGIBILITY

Name

Criminal History

Date Verified

Outcome

Nurse Aide Registry

Date Verified

Outcome

Employee Misconduct

Date Verified

Outcome

Employment Verification

Date Verified

Outcome

Verifier Signature

Certified Nurse Associate

EDUCATION

EMPLOYMENT HISTORY

REFERENCES / CONTACTS

Employment Offer Notice

📍 Service Areas We Proudly Cover in Texas

DISCLAIMER
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties

EDUCATION

EMPLOYMENT HISTORY

REFERENCES / CONTACTS

Employment Offer Notice

📍 Service Areas We Proudly Cover in Texas

DISCLAIMER No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties

DISCLAIMER
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties