APPLICATION FOR EMPLOYMENT

246.01 APPLICATION FOR EMPLOYMENT
Emerald Total Care

EQUAL OPPORTUNITY EMPLOYER
Date

MonthDayYear
Date
Name

First NameMiddleLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Residence
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date available for work

MonthDayYear
Date
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship
Are you at least 18 years of age?

YesNo
Are you presently employed?

YesNo
Are you eligible to work in the U.S.?

YesNo
Do you possess a valid driver's license?

YesNo
Position you are applying for?
Salary Requirements:
Are you available to work:

Full-timePart timeShift workTemporary
How did you hear about Emerald Total Care.?
Skills and Qualifications Summary:
Certifications/Licenses applicable to the position applying for:
List any career objectives you may have:
Have you ever been convicted of a felony?

YesNo
If so, when, where, and disposition of offense?

EDUCATION

	School Name/Address/Telephone	Number of Yrs. Completed	Area of Study	Did you graduate?
LINE 1
LINE 2
LINE 3
Line 4

Work History

	Company Name Phone/Address	Supervisor	Dates Month/Year (Start & End)	Position Held	Rate of Pay	Reason for Leaving
LINE 1
LINE 2
LINE 3
Line 4

References

Provide details on two non-related references who are not related to you and are not previous employers.
Reference 1 Name
Relationship
Telephone Number
Address
Years Known
Reference 2 Name
Relationship
Telephone Number
Address
Years Known
Optional: Reference 3 Name
Relationship
Telephone Number
Address
Years Known
I understand and agree that: Any material misrepresentation or deliberate omission of a fact in my application may result in refusal of or if employed, immediate termination from employment. Although management makes every effort to accommodate individual preference, business needs may at times make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment. It is my understanding that Emerald Total Care of will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Emerald Total Care and I release from liability any person giving or receiving such information. I agree that my employment is at will and may be terminated by Emerald Total Care or at any time with or without notice or cause and without liability for wages or salary except such as may have been earned at the date of such termination. I further understand this is an application for employment and that no employment contract is being offered, nor will any result from my employment with Emerald Total Care I understand that if I am employed, such employment is for no definite period of time and that Emerald Total Care can change wages, benefits, and conditions at any time.

I acknowledge that any or all representation or written statements which may have been made to me to the contrary of this paragraph are expressly disavowed and may not be relied upon.
Signature*

Clear
Date

MonthDayYear
Date

Employee Professional Reference Check Form

Reference 1
Applicant Name

First NameLast Name
Social Security Number
Facility/Employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Position Held:
Signature*

Clear
Date

MonthDayYear
Date

Employee Professional Reference Check Form

Reference 2
Applicant Name

First NameLast Name
Social Security Number
Facility/Employer
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Position Held:
Signature*

Clear
Date

MonthDayYear
Date

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, l 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.

L 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. lf 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.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

	AM	PM	Days	Nights
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Emerald Total Care

References

Companion Skills and Availability Checklist

Employee Professional Reference Check Form

Employee Professional Reference Check Form