Position Applying For : ___________________________ Full Time Part Time T Part Time Per Visit T Pool Shift: Day Evening Night W/E If you are not a U.S. Citizen, do you have the legal right to remain permanently in the U.S.? Yes n No Salary Requirement: $ Date Available: Do you have adequate means of transportation to get to work on time each day and when called in short notice during normal working hours? Yes No __________________________________________________________________________________________
Educational History
High School : City, State, Country Graduated: Yes No
College/University City, State, Country Graduated : Yes No
College/University : City, State, Country Graduated : Yes No
Other: From To
City, State, Country :
Please review and sign
In submitting 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, imcomplete, or misrepresented, I understand and agree that the Agency ot 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 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 purposeof Employee Misconduct Registry is to ensure that unlicensed personnel commit acts of abuse, neglect, exploitation, or misappropriation or misconduct against residents and consumers are denied employment HHS-regulated facilities and agencies; 2) the State of Texas maintains registry of allnurse 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, 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 such information concerning my employment with them as may be requested, and also auntorize 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.