* = Required Information
Application for Employment
It is
A-One Plus Home Health Care Agency LLC
’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.
Applicant Name:
*
Email Address
*
City
*
State
*
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Home Phone:
*
Cell Phone
Are You at Least 18 Years Old?
Yes
No
Position Applying For:
Please select position
Office Administration
RN
LVN
Attendant
Full Time
Part Time
Part Time Per Visit
Pool
Shift:
Day
Night
Evening
Week End
Salary Requirements:
Date Available:
If you are not a U.S. Citizen, have you the legal right to remain permanently in the U.S?
Yes
No
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?
Yes
No
Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?
Yes
No
If Yes, please give date, place and nature of each such conviction.
Are you presently charged with any violation of the law other than traffic violation?
Yes
No
If Yes give date, place and nature of each such conviction.
Educational History
Type of School: High School
Name
Location of School
Circle Last Year Attended
9
10
11
12
Graduated
Yes
No
Degree
Type of School: College
Name
Location of School
Circle Last Year Attended
9
10
11
12
Graduated
Yes
No
Degree
Other
Name
Location of School
Last Year Attended
From:
To:
Graduated
Yes
No
Degree
List professional licenses you possess. Indicate type of license, number and state
List languages spoken other than English:
List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:
In case of an emergency notify:
Relationship:
Out of State Contact, if possible:
Relationship:
Work History
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
City
State
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone Number
Supervisor's Name
Date Started
Date Left
Type of Business
Full Time
Part Time
Per Visit
Salary
Reason For Leaving
OK to Contact Supervisor
Yes
No
Describe your job title, responsibilities and accomplishments
Company Name
City
State
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone Number
Supervisor's Name
Date Started
Date Left
Type of Business
Full Time
Part Time
Per Visit
Salary
Reason For Leaving
OK to Contact Supervisor
Yes
No
Describe your job title, responsibilities and accomplishments
Company Name
City
State
Please select state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Phone Number
Supervisor's Name
Date Started
Date Left
Type of Business
Full Time
Part Time
Per Visit
Salary
Reason For Leaving
OK to Contact Supervisor
Yes
No
Describe your job title, responsibilities and accomplishments
PERSONAL REFERENCES:
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
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:
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;
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;
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 to release full information concerning my license status and my license history.
Applicant Signature:
*
Date:
Submit