Pitre Housing Residential Care – Employment Application
Thank you for your interest in joining Pitre Housing Residential Care. We are a provider supporting individuals enrolled in the HCS and TxHmL waiver programs. Please complete the application below, and a member of our team will contact you regarding next steps.
APPLICANT INFORMATION
Name
*
First Name
Last Name
Date-of-birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
POSITION & AVAILABILITY
Position Applying For:
*
Direct Care Staff (Respite / Attendant Care)
Personal Assistance Services
Transportation Driver
Residential Support Staff
Registered Nurse (RN)
Licensed Vocational Nurse (LVN)
Behavioral Support Professional
Administrative Assistant
Availability:
*
Full-time
Part-time
PRN/ As needed
Contract
Preferred Work Schedule:
*
Weekdays
Evenings
Weekends
Flexible
Night Shift
Day Shift
EXPERIENCE
Do you have any of the following certifications?
*
RN/LVN
CNA
PPR/First Aid
Medication Aid
None
Do you have experience working with individuals with disabilities?
*
Yes
No
Please list your last three (3) employers, beginning with your most recent including dates. Attach a resume if additional space is needed. A resume does not replace the employment history section below.
*
Which populations have you worked with? (Check all that apply)
*
CFC
Respite
Elderly
Pediatrics
Behavioral Health
Home Health
Have you ever been terminated or asked to resign from a position?
*
Yes
No
If yes, explain:
*
Are you eligible for rehire by your previous employer?
*
Yes
No
Don't Know
TRANSPORTATION & RELIABILITY
Do you have reliable transportation?
*
Yes
No
Are you willing to transport clients if needed?
*
Yes
No
Do you have a valid Texas driver's license?
*
Yes
No
Driver's License Number & Expiration Date:
*
Have you had any moving violations or at-fault accidents within the past three (3) years?
*
Yes
No
Have you ever had your driver's license suspended or revoked?
*
Yes
No
I understand that if hired for a position requiring transportation, I must maintain a valid driver's license, current automobile insurance, and immediately notify Pitre Housing of any changes to my driving status. I also understand that my driving record may be reviewed as a condition of employment and periodically thereafter.
*
I agree.
BACKGROUND & ELIGIBILITY
Have you ever been convicted of, pleaded guilty to, or pleaded no contest to a misdemeanor or felony that has not been sealed or expunged?
*
Yes
No
Have you ever been placed on any state or federal exclusion list, including the Office of Inspector General (OIG) exclusion list or Texas Medicaid exclusion list?
*
Yes
No
If yes, please explain:
*
2. Do you currently have any pending criminal charges?
*
Yes
No
If yes, explain:
*
Have you ever been found by a court or government agency to have committed abuse, neglect, or exploitation of a child, elderly person, or person with a disability?
*
Yes
No
Have you ever been denied employment or terminated from a healthcare, home health, HCS, TxHmL, assisted living, nursing home, or direct care position because of misconduct or policy violations?
*
Yes
No
If yes, explain:
*
Have you ever been convicted of a criminal offense that would prevent you from working with vulnerable populations (children, elderly, or individuals with disabilities)?
*
Yes
No
Have you ever had a professional license or certification suspended, revoked, restricted, or placed on probation?
*
Yes
No
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever worked for Pitre Housing before?
*
Yes
No
Do you have any relatives currently employed by Pitre Housing?
*
Yes
No
Are you able to perform the essential functions of the position you are applying for, with or without reasonable accommodation?
*
Yes
No
DOCUMENT UPLOAD
Drivers License
*
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Resume
*
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High school diploma or GED
*
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Certifications (if applicable)
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of
BACKGROUND CHECK CONSENT
I authorize Pitre Housing Residential Care LLC to conduct background screenings as part of the employment process.
Social Security Number:
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
FINAL ACKNOWLEDGEMENT
I understand that submission of this application does not guarantee employment. All applicants must complete screening, background checks, and training requirements.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: