* = Required Information

Please complete entire application. Do not leave any spaces blank. If the field does not apply to you please enter N/A in that field.

To be considered for employment, you must have:

  • VALID TDL/ID and
  • Social Security Card/Resident Card

Application CANNOT be processed or approved for hiring without the above items.

All prospective employees will receive consideration without discrimination because of race, color, sex, age, natural origin, or handicap. All information provided here-in will be kept confidential.

Do not leave any spaces blank. Write N/A in blank spaces.

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Days and hours available for work
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EDUCATION

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PROFESSIONAL REFERENCES


EMPLOYMENT

--List the last five years employment history, starting with the most recent employer.

Dates of Employment

Pay


Dates of Employment

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Dates of Employment

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Dates of Employment

Pay

The State of Texas requires the Agency to inform the applicant of our request to perform the following background checks. These background checks are performed on every employee regardless of skill or experience before hire and each year thereafter. Before you are considered for employment, employee misconduct checks must be conducted. Your initials and signature will permit us to proceed with state regulations.

I give the Agency permission to conduct an Employee Misconduct check on me.

I give the Agency permission to conduct a Nurse Aide Registry Check.

I give the Agency permission to conduct a Medication Aide Registry Check.

I have no offense in Employee Misconduct Registry, Nurse Aide Registry, or the Medication Registry, which is considered as unemployable due to a finding that I have committed an act constituting “reportable conduct”.

The State of Texas requires the Agency to inform the applicant of our request for a criminal check 115.54 (4).

I have been informed that in compliance with Texas Senate Bill 332 (House Bill 1466) passed by the 71st Legislature, this agency is required to perform criminal history checks on all employees who provide care or have access to medical records of patients in an adult facility or in a client’s home.

I have been informed that the criminal history check will be conducted by the Texas Department of Human Services, office of the Inspector General, on behalf of the Texas Department of Health and Texas Department of Human Services contract Administrators.

I understand that any records received by TDHS, are privileged information and are for the exclusive use of TDHS, the Texas Department of Health, and the facility for which TDHS requested the information. The records may not be released or otherwise disclosed to any person or agency except on court order or with the written consent of the person being investigated.

I understand that the offer of employment with this agency is conditional. This will be made permanent once the criminal history check is returned and reveals that there have been no convictions or offenses prohibiting work as outlined by the law.

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