First Name *

Last Name *

Middle Initial

Today's Date *

Social Security No. *

Home Phone

Mobile Phone *

Current Address

Street *

City *

State *

Zip Code *

Previous Address

Street

City

State

Zip Code

Are you 18 years of age or older? *

APPLICANT NOTE: This application form is for use in evaluating your suitability for employment. It is not an employment contract.
Please answer all appropriate questions completely and to the best of your ability. False or misleading statements are grounds for
refusal or termination of employment and benefits. Federal law provides penalties for false statements on documents related to U.S.
employment eligibility. The company reserves the right to determine an applicant’s eligibility for employment or termination of
employment while governed by state and federal statutes regarding equality without discrimination of sex, creed, race, natural origin,
religious preference or disability. Reasonable accommodation may be available to persons otherwise able to fulfill job responsibilities.

All Texas Unlicensed Persons with face-to-face contact with clients will have pre employment and annual EMR/NAR check *

I acknowledge the above statement

I certify that I: *

HAVE NOT been excluded from Medicare, Medicaid, and/ or any other federally funded healthcare program.

HAVE been excluded from Medicare, Medicaid, and/ or any other federally funded healthcare program.

For which position are you applying? *

Professional License No.(if applicable)

Expiration Date:

What date can you start? *

What category would you prefer? *

Full Time

Part Time

PRN

High School

Name

City/State

Did You Graduate?

College

Name

City/State

Did You Graduate?

Trade, Business or Correspondence

Name

City/State

Did You Graduate?

Other

Name

City/State

Did You Graduate?

List any job-related military training, experience or related courses of study:

Experience

Most Recent Employer

Name *

Address *

City, State, Zip *

Phone *

Supervisor *

May We Contact? *

Yes

Dates Employed *

Salary/Pay Rate

Position/Duties *

Employer 2

Name

Street Address

City, State, Zip

Phone

Supervisor

May We Contact?

Yes

Dates Employed

Salary/Pay Rate

Position/Duties

Employer 3

Name

Street Address

City, State, Zip

Phone

Supervisor

May We Contact?

Yes

Dates Employed

Salary/Pay Rate

Position/Duties

In which states have you lived in the past seven years? *

Have you used any names or Social Security numbers other than those on this form? *

Yes

If yes, please list

Have you ever been convicted, fined, imprisoned, placed on probation or given a suspended sentence by any court, including court martial, or have you forfeited bail in connection with any offense? Do not include: (1) juvenile offenses if the record has subsequently been sealed by court order; (2) traffic violations unless an issuance of a warrant resulted. *

Yes

Criminal convictions do not necessarily bar the applicant from employment. If yes, give the following information for each offense:

Offense & Date

Offense City/State

Sentence And/Or Disposition

References

Include only individuals familiar with your work ability. Do not include relatives.

Professional Reference - Name *

Professional Reference - Address/Phone *

Professional Reference - Years Known/Relationship *

Personal Reference - Name *

Personal Reference - Address/Phone *

Personal Reference - Years Known/Relationship *

QUALIFICATIONS (combination of education, experience and other personal abilities you feel make you qualified for the position):

I am familiar with the mental and physical requirements of the job for which I am applying

I certify that I am able to perform the tasks required (with or without accommodation) in the job for which I am applying.

I request the following accommodation to explain, demonstrate or continue the employment application process:

CERTIFICATION AND RELEASE: I certify that I have read and understand the Applicant Note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and its agents, including consumer reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle records. I release all persons, schools, companies and law enforcement authorities from any liabilities for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs before and during employment. Illegal drugs means any drug which is not legally obtainable or which is legally obtainable but has not been legally acquired or administered This agency will not hire continue to employee anyone who is under a sanction or has been excluded from Medicare, Medicaid or other federally funded health care programs.

Signature *

Clear

Date *

The Agency is an equal employment opportunity employer dedicated to an employment policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability or national origin.

This application will remain active for 45 days. If you desire continued consideration for employment, you may reapply after that time.