Adorn Health Care Application

Adorn Health Care Supervising RN Application

The completion of this application form is part of stage one. This application will be reviewed, and a decision made as to whether to proceed to stage two, the interview, based on this information. Adorn Health Care is an EQUAL OPPORTUNITY EMPLOYER.
Please be advised that all information collected is encrypted and secured and not shared with third parties.
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Email Address
example@example.com
Phone Number
Current Address
Date of Birth

MonthDayYear
Date
Social Security Number*
List other states you've worked:
Are you presently employed?

YesNo
Date Available to work

MonthDayYear
Date
Do you have your own transportation?

YesNo
Valid Texas required car insurance?

YesNo

	Driver License #	State Issued	Expiration Date [MM/DD/YY]
Enter valid DL info

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

YesNo
Data Protection Statement The personal information (data) collected on this form, are used only for the purpose of this employment. Equality of Opportunity Statement The Agency’s Equal Opportunities Policy covers all employees, or potential employees, and embraces the principle that all people shall be treated equally, regardless of their age, gender, ethnic origin, nationality, colour, religion, marital status, sexual orientation, religion or belief, disability, or offending background.

Availability Checklist

Please only include days/times that you are available to work.
Insert an "AM" time to a "PM" time or check days or nights. Days or nights may be 8–12 hour shifts. Keep in mind your travel time. The Agency provides caregivers to clients 24 hours per day.

Education - School/College/University

List previous three (3) educational institutions attended, beginning with the most recent
Training History/Professional Status
Do you have a valid First Aid/CPR Certification?

YesNo
If YES, please attach copy of certificate to application

Cancelof
Have you ever had any professional or occupational license or certification suspended/revoked?

YesNo

Employment History: 3 - 5 years of employment

If possible, include your RN work history
How did you hear about Adorn Health Care?
Details of past employment starting with the most recent. At least 3 years of work history must be provided.
May we contact employer(s) listed?

YesNo
Have you ever been discharged (fired, laid-off, etc.) from a job?

YesNo
If you are successful in the application, would you require a working permit prior to taking up employment?

YesNo

References

List the name, relationship, number of years acquainted, and phone number of 3 references that are familiar with your work experience. Please contact these references and let them know they will be contacted. (Do not list family or family friends).
Please list 1 PERSONAL reference (Can be family or family friend)
Record of conviction does not necessarily disqualify an applicant from employment considerations.
Have you been convicted of a felony or misdemeanor, or had adjudication deferred on any felony or misdemeanor, or have you been incarcerated or on parole in the last ten (10) years? Include Driving While Intoxicated.**

YesNo
If yes, please explain
Have you ever been charged with a crime that has not yet resulted in a plea of guilty, court trial, deferred adjudication or dropping of the charge?*

YesNo
If yes, please explain
Resume (If already submitted, disregard)

Cancelof
I understand and agree that any conditional offer of employment is contingent upon the satisfactory completion of a background (to include fingerprints)/consumer report and meeting the organization's drug testing requirements. If you select 'no', you will not be considered for this position.*
I understand and agree that depending upon the work location and position type, I may be subject to random drug and alcohol testing and annual background checks, as permitted by law. Successful completion of these screenings is required for continued employment.*
I understand and agree that any conditional offer of employment is contingent on my reviewing, understanding, and signing the organization's Mutual and Binding Arbitration Agreement. If you select 'no', you will not be considered for this position.*
SIGNATURE and DECLARATION

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 Adorn Health Care LLC 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 Adorn Health Care LLC 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 Adorn Health Care LLC or me 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 Adorn Health Care LLC. I understand that if I am employed, such employment is for no definite period of time and that Adorn Health Care LLC can change wages, benefits, and conditions at any time.

I acknowledge that any oral 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.
Date*

MonthDayYear
Date
Signature*

Clear
Confidentiality Statement

We consider it an essential practice to uphold the confidentiality of your personal information. We do not allow third parties to gain access to your personal information without your consent. Information that is collected through online forms will be kept confidential.
Please verify that you are human*
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Adorn Health Care Supervising RN Application

Availability Checklist

Education - School/College/University

Employment History: 3 - 5 years of employment

References