Application Form

Please review and Submit
In making application for employment:
 I certify that the information on this application is true and complete for all practical purposes. It may be verified by any Agency or affiliate. Should a position be offered and later is found that the information is significantly untrue, incomplete or misinterpreted, I understand and agree that the Agency or its affiliate are relieved of all commitments, financial or otherwise pertinent to employment and that I am subject to immediate discharge without recourse.

 I understand and agree that if I’m offered employment by the Agency, my employment will be for no definite term, and that either I, or the Agency 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 Agency.
 I understand if I have direct patient contact, that the Agency will perform a background check, including criminal history check, OIG exclusion list check, (if applicable), and any additional check if required, by accrediting body standards or State Regulations. I further understand if I am an unlicensed person, the Agency will perform 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 commits acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-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 Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of residents 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 HHS-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. I understand that refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application, or termination of employment.

Release: I hereby authorize any prior employers to provide such information concerning my employment with them as maybe requested and 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 history.