Zionrock Healthcare Services Leave this field blank First Name: Last Name: Middle Name: Other Names used, maiden, aliases: Email Address: Phone Street Address: Apt No.: (optional) City State: Zip Code: Position Applying For: Please select position Registered Nurse (RN) Licensed Vocational Nurse (LVN) Certified Nursing Assistant (CNA) Personal Care Attendant (PCA) Other Salary Requirements: $ Date Available: Preferred Job Locations: Are You at Least 18 Years Old? Yes No Are you a citizen of the United States? Yes No If you are not a U.S. Citizen, do you have the legal right to remain and work 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 5 years? Yes No If Yes, please give date, place and nature of each such conviction: (optional) Educational Background: High School Name (optional) City/State: (optional) Last Year Attended (optional) 9 10 11 12 Graduated: (optional) Yes No Degree (optional) College School Name: (optional) City/State: (optional) Degree: (optional) Graduated: Yes No Other: List additonal education and professional licenses. Please indicate type of license, number and state: (optional) Languages spoken: Other applicable skills for the position applied for: Work History: Company Name 1 (Most Recent) City: State: Zip Code Phone Date Started Date Ended Describe your job title, tasks & responsibilities, accomplishments Salary Reason For Leaving Supervisor's Name OK to Contact Supervisor? Yes No Company Name 2 City: State: Zip Code Phone Date Started Date Ended Describe your job title, tasks & responsibilities, accomplishments: Salary Reason For Leaving Supervisor's Name OK to Contact Supervisor? Yes No Company Name 3 (optional) City: (optional) State: (optional) Zip Code (optional) Phone (optional) Date Started (optional) Date Ended (optional) Describe your job title, tasks & responsibilities, accomplishments: (optional) Salary (optional) Reason For Leaving (optional) Supervisor's Name (optional) OK to Contact Supervisor? (optional) Yes No Emergency Contact Person: Note: This information is mandatory. Please provide reference. Relationship: Phone: Personal Reference 1: Note: This information is mandatory. Please provide reference. Relationship: Phone: Personal Reference 2: Note: This information is mandatory. Please provide reference. Relationship: Phone: Professional Reference 1: Note: This information is mandatory. Please provide reference. Position/Company: Phone: Professional Reference 2: Note: This information is mandatory. Please provide reference. Position/Company: Phone: PLEASE REVIEW AND SIGN: 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. Yes No 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. Yes No 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. Yes No 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: 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. Yes No 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. Yes No STATEMENT OF EMPLOYABILITY: I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act. Criminal History Check I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact or have access to patient records until results are returned. I will be notified of results. I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge. Yes No Applicant's Electronic Signature (By writing my name here, I agree to have digitally signed this Employment Application Form.) Today's Date: Submit
