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Better & Faster
Home Health Software

Work with Us?

Please Fill The Form Below To Start the Employment Process

Contact Information

Full-name M: Address
Email City: State
Phone Type Zip

Work Availability

Days/Hours available to work:
Position Applied For No Preference/Any Thurs
Salary Desired Mon Fri
Hourly Annually Tue Sat
Wed Sun
 
How many hours a week are you available to work? When are you available for work to begin work?
Date Picker
 
Employment desired
Full Time Part Time Full or part time
 
Can you work nights?
Yes No
 

Education

Type of School Name of School Location Number of years Completed Major Degree
High School
College
Bus. or Trade School
Professional School
 

Transportation

Transportation
What is your means of transportation to work?
Do you have a valid Texas driver's license Yes No
If yes, driver's license number
Expiration date
Date Picker
Have you had any accidents in the last three years? No Yes
If yes, how many
Have you had any moving violations during the last three years? No Yes
If yes, how many
.

Office Skills

Typing Yes No If yes, WPM:
Computer Proficiency PC Mac
10-Key Yes No
Word Processing Yes No WPM:
Other Skills:
.

Please list two references

Name:
Relation:
Company:
Position:
Address:
Phone:
Name:
Relation:
Company:
Position:
Address:
Phone:
.

Military Service

Have you ever been in the armed forces? Yes No
Are you now a member of the national guard? Yes No
Specialy
Date entered
Date Picker
Date discharge
Date Picker
 
 

Work Experience

Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name
May we contact your current employer? Yes No
Name of Employer Name of last Supervisor
Address Phone
City State Zip
Employment Dates Pay / Salary
From:
Date Picker
Starting:
To
Date Picker
Ending
Currently employed
 
 
Name of Employer Name of last Supervisor
Address Phone
City State Zip
Employment Dates Pay / Salary
From:
Date Picker
Starting:
To
Date Picker
Ending
 
 
 
Name of Employer Name of last Supervisor
Address Phone
City State Zip
Employment Dates Pay / Salary
From:
Date Picker
Starting:
To
Date Picker
Ending
 
 
 
 
 

Crime conviction?

Have you ever been convicted of a crime?
NoYes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
 

Agreement

In exchange for the consideration of my job application by (hereinafter called the Company), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of , or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
I also understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations.
I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
Electronic Signature Date Completed
Date Picker
 
 
This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
Thank you for completing this application form and for your interest in our business.