Senior Care Wichita Falls Application for Employment

 
 Date*  
 We are an Equal Employment Opportunity Employer-M/F/Protected Veteran Status/Disability.

 PERSONAL INFORMATION

 Name (First)*
 (Middle)  
 (Last)*
   Other name used while working
 Home Address (Street)* (City)* (State)* (Zip)* Home Phone Number*
     
    Social Security Number
Are you a U.S. Citizen or are you authorized by the INS to work? Yes  No  
    Driver's License Number, Texas I.D. or Other Identifying Number
Are you over the age of 18? Yes  No  
Date of Birth (DD/MM/YYYY):  
Have you ever been convicted of anything other than traffic violations? Yes  No    
If yes please explain:   Please be advised that this Facility may have a smoke free environment policy.
Do you agree to work in a smoke free environment?
 Yes No     
NOTE:
WE ROUTINELY PERFORM CRIMINAL CONVICTION CHECKS AS REQUIRED BY TEXAS LAW FOR NURSING HOMES AND ASSISTED LIVING HOMES.
 
  

 EMPLOYMENT DESIRED

Have you applied for employment at this facility before? Yes  No  Date you can start Starting Desired Salary
If you have applied before when?     
Any shift you are not willing to work? 
Have you ever been employed at any nursing facility? Yes  No   
 
If so, please list the name(s) of the facility(ies) and the dates of employment.  Position Desired Shift Desired 
 When?     
Have  you ever been excluded from participating in any federal or state health care program? Yes  No   
Are you employed now? Yes  No 

LIST APPLICABLE SKILLS AND/OR LICENCES

If so, may we contact your employer? Yes  No  
Are you currently on layoff or leave from another company? Yes  No  
Are you available for full time work? Yes  No  
Are you available for part time work? Yes  No  
Highest grade completed (choose one)Grade School
High School
College
Name and Location of last school attended (name of school) (location)
   
Vocational or trade training 
List any additional skills, training, experience or other qualifications 
relating to the position for which you are applying. 

 REFERENCES

 (LIST TWO PEOPLE WHO YOU HAVE KNOWN FOR AT LEAST ONE YEAR)

 (name)

 (address)

 (telephone number)

 (years acquainted)

    
    

EMERGENCY (IN CASE OF EMERGENCY PLEASE  NOTIFY)

  

 (name)

  (address)

 (telephone number)

 (relationship)

   
      

EMPLOYMENT HISTORY

Name and address of company
 From:
 To:
 Describe the work you did:
Telephone:
Supervisor:
 
 Beginning Salary
 Ending Salary
 Reason for leaving:
 
   
 
 
Name and address of company
 From:
To:
 Describe the work you did:
Telephone:
Supervisor:
Beginning Salary
 Ending Salary
 Reason for leaving:
  
 
Name and address of company
 From:
 To:
 Describe the work you did:
Telephone:
 Supervisor:
 Beginning Salary
  Ending Salary
 
 Reason for leaving:
   
 
Name and address of company
 From:
 To:
 Describe the work you did:
Telephone:
Supervisor:
 
 Beginning Salary
 Ending Salary
 Reason for leaving:
   

PLEASE READ AND COMPLETE BEFORE SUBMITTING

 
All statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, would affect this application unfavorably. I agree that this facility and my previous employers shall not be held liable in any respect if a job offer is not extended, is withdrawn, or my employment is terminated because of false statements, omissions or answers made by me on this application.
YesNo
I authorize my previous employers, schools or persons named as references to give any information regarding employment or educational record.
YesNo
I understand that operating conditions may require me to temporarily work shifts other than the one for which I am applying and I agree to such scheduling changes as directed by my supervisor or the facility administrator.
YesNo
In the event of my employment I agree to comply with all rules and regulations as set forth in any communication distributed to employees.
YesNo
I agree to provide the required documentation to comply with the Immigration and Control Act of 1986 on or before the first day of employment.
YesNo
I understand that, if hired, my employment is "at will" and is for no definite period and may be terminated at any time without any prior notice.
YesNo
I agree as a condition of initial and continued employment, to submit to substance abuse testing (such as alcohol, drugs, etc) at anytime at the request of my employer and I understand that refusal to submit to substance abuse testing may be grounds for immediate dismissal.
YesNo
I understand that my employer does not carry workers' compensation insurance.
YesNo
I understand that if I want disability insurance, I am responsible for obtaining it myself.
YesNo
Can you perform the essential functions of the position for which you are applying?
YesNo
 
 

 (If you have any question as to what functions are applicable to the position for which you are applying, please ask the interviewer.)

 BY CLICKING THE SUBMIT BUTTON I ATTEST THE INFORMATION ABOVE IS TRUE.

 

Foursquare Healthcare is an “EEOE-M/F/Protected Veteran Status/Disability”. In the event an individual with disability and disabled veteran requires reasonable accommodation in completing any part of the employment application process, they may contact the Corporate HR Director at 972-303-9000 or fax to 972-303-9700.