bahsegel

bahsegel

Application for Employment

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law

    Required fields are marked with an asterisk.

    Are You at Least 18 Years Old?

    Position Applying For:

    Shift:

    If you are not a US Citizen, do you have the legal right to remain permanently in the US?

    Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

    Educational History

    Type of School

    Name & Location of School

    Last Year Attended

    Graduated

    Degree

    High School

    College

    College

    Other

    From

    To





    Work History

    Have you previously been employed ? (If any, you can add up to 3 previous employers)

    Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient:

    Company Name

    Complete Address incl City/State/Zip

    Phone Number

    Supervisor’s Name

    Date Started
    Date Left

    Type of Business

    Reason For Leaving

    OK to Contact Supervisor

    Add another Company

    Company Name

    Complete Address incl City/State/Zip

    Phone Number

    Supervisor’s Name

    Date Started
    Date Left

    Type of Business

    Reason For Leaving

    OK to Contact Supervisor


    Add another Company

    Company Name

    Complete Address incl City/State/Zip

    Phone Number

    Supervisor’s Name

    Date Started
    Date Left

    Type of Business

    Reason For Leaving

    OK to Contact Supervisor

    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, I 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.

    I 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. If 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 and 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 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 HHS-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 Health and Human Services (HHS) 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 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.

    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.