Home Care & Home Health Care Jobs In Dallas

Application for Employment

It is this facility's policy to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, or disability.

Social Security Number

Are you at least 18 years old?

Yes No

Position applying for

Full Time Part Time Part Time Per Visit Pool

Shift

Day Evening Night W/E

If you are not a US Citizen, have the legal right to remain permanently in the US?

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 confinementfollowing a conviction for any criminal offence within the past 7 years?

Yes No

If Yes, please give date, place and nature of each such conviction.

High School Name & Location

Check last year attended

9 10 11 12

College Name & Location

Check last year attended

1 2 3 4

List any professional licenses you possess. Indicate type of license, number and state

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate race, color, religion, sex, natrional origin or disability.

List any languages spoken other than English:

List any other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:

Emergency Contact Name

Emergency Contact Number

Personal References (Name, Phone, Relationship)

Please review and sign

In making application for employment:

By checking this box 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.

By checking this box 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 and investigative report is made, I understand that I will receive disclosure of additional information concerning the nature and scope of the investigation.

By checking this box 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 materiel terms and is signed by me and the Administrator of the facility.

By checking this box I understand, if I am an unlicensed person who has direct patient contact, the agency will perform a criminal history check per State Regulations.

Release: By checking this box 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 and 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.

Attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient

Ok to Contact Supervisor?

Yes No

Type of Business

Full Time Per Visit

Describe your job title, responsibilities and accomplishments

Ok to Contact Supervisor?

Yes No

Type of Business

Full Time Per Visit

Describe your job title, responsibilities and accomplishments

Ok to Contact Supervisor?

Yes No

Type of Business

Full Time Per Visit

Describe your job title, responsibilities and accomplishments

Fill the Reference Request document on from the following link and upload it below:

Reference Request

Employment Opportunities for Home Caregivers in Dallas

Application for Employment

Educational History

Work History

Reference Request

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