* = Required Information

APPLICATION FOR EMPLOYMENT

Date:*

Full Name:* Social Security No: Present Address:*

City:* State:* Zip:* Phone No:* Pager No:

Permanent Address:*

Notify in case of an emergency:

Name: Address: Phone No:

Are you 18 years or older?    YesNo Have you ever been convicted of a felony? YesNo

If YES, please explain:

Please note that we are required by Texas law to perform a Criminal Conviction History Check on all Unlicensed personnel and are prohibited from permanently employing any person whose check reveals certain past criminal convictions.

Referral Source:

Friend (Name): Relative (Name): Newspaper: Walk-in: Employment Agency: Other:

EDUCATION

SCHOOL NAME AND ADDRESS YEARS COMPLETED GRADUATE AREA OF STUDY DEGREE RECEIVED HIGHSCHOOL 1234 YesNo College 1234 YesNo Trade, Business or Vocational School 1234 YesNo

US Veteran? YesNo

Dates of Service: Nature of Duty or Training: Other Job Related Skills: Knowledge of a Foreign Language:

PROFESSIONAL LICENSES AND/OR CERTIFICATIONS

TYPE AND NUMBER ISSUED BY WHICH STATE OR ORGANIZATION DATE ISSUED/EXPIRATION

EMPLOYMENT DESIRED AND AVAILABILITY

Position Desired: Salary Desired:

Date Available:

Are you willing and able to work?

Weekends?                               YesNo Holidays?                               YesNo

Do you have responsibilities that would limit your ability to work?        YesNo

If YES, please explain:

Do you have your own reliable transportation?        YesNo

Driver's License No. and State:

Auto Insurance?        YesNo

EMPLOYMENT RECORD

Are you currently employed?        YesNo We routinely contact an applicant's current employer for reference checks. Would this pose any particular difficulty for you?        YesNo

If YES, please explain:

LIST PREVIOUS EMPLOYMENT INFORMATION:

Current or Last Employer

Dates Employed From: to

Company Name: Phone: Address:

City: State: ZIP:

Position/Duties: Supervisor: Hourly Wage Reason for Leaving:

Previous Employer

Dates Employed From: to

Company Name: Phone: Address:

City: State: ZIP:

Position/Duties: Supervisor: Hourly Wage Reason for Leaving:

Previous Employer

Dates Employed From: to

Company Name: Phone: Address:

City: State: ZIP:

Position/Duties: Supervisor: Hourly Wage Reason for Leaving: Please explain all periods of unemployment:

Have you ever been terminated from employment? YesNo

If YES, please explain:

Use this space to give us other information about your personal qualities, work style, interpersonal skills or communication skills which would assist us in placing you:

REFERENCES

NAME ADDRESS PHONE YEARS KNOWN

PRE-EMPLOYMENT MEDICAL HISTORY AND MOBILITY EVALUATION

SECTION 1 APPLICANT INFORMATION STATEMENT (TO BE READ BY APPLICANT)

Before an offer of employment can be made, the section below must be completed. Advent One Home Care Agency, is an equal opportunity employer who affirmatively seeks to employ qualified handicapped individuals. The following evaluation will assist us in efforts to reasonably accommodate our work environment to your needs.

SECTION 2: MEDICAL HISTORY

a. State any physical defects or limitations that you have:

b. Employment for the company requires all employees to be fit to perform any physical activities related to their job, as well as to appear regularly and on time for work as assigned. In that regard, do you have any of the following ailments? BACK TROUBLE HEART TROUBLE BREATHING PROBLEMS HERNIA DIABETES TRICK JOINTS DIFFICULTY BENDING ULCERS DIZZINESS/BLACKOUTS CANCER EPILEPSY ALCOHOL ADDICTION HIGH BLOOD PRESSURE DRUG ADDICTION CIRCULATORY PROBLEMS ANY COMMUNICABLE DISEASE

Describe any checked answers. List any prescribed medications you are now using:

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 who has face-to-face patient/client contact, that the agency will perform a criminal history check per State Regulations as well as 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 DADS-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 Department of Aging and Disability Services (DADS) 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 DADS-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 10 release full information concerning my license status and my license history.

Date*

* Security Code