Job Application Form

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, genetic information, sex, marital status, national origin, or disability.

List languages spoken other than English:

List other skills applicable to the position for which you are applying:

Emergency Contact Information

In case of emergency, notify:

Out of state contact, if possible:

Work History

List all employment starting with the most recent. If you need more room, note that there is further work history in your uploaded resume.

Still working here?

Yes No

Describe your job title, responsibilities and accomplishments:

Okay to Contact Supervisor?

Yes No

Still working here?

Yes No

Describe your job title, responsibilities and accomplishments:

Okay to Contact Supervisor?

Yes No

Still working here?

Yes No

Describe your job title, responsibilities and accomplishments:

Okay to Contact Supervisor?

Yes No

Please review, acknowledge acceptance, 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 have direct patient contact or contact with patient records, that the agency will perform a criminal history check per Federal Regulation, as well as a check of the Nurse Aide Registry and Employee Misconduct Registry for unlicensed employees. 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 to release full information concerning my license status and my license histmy.

Apply to Work at Vantage Hospice

Educational History

Emergency Contact Information

Personal References

Work History

Please review, acknowledge acceptance, and sign.

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