Texas Angels Home Health Care, Inc. Employment Application

General Information

Employee Type *

First Name *

Middle Name (if no middle name type NONE) *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Cell Phone *

Home Phone *

Email Address *

Social Security Number (XXXXXXXXX) No Spaces *

Military Veteran> *

Yes

No

*

Female

Male

Marital Status *

Date of Birth (MM-DD-YYYY) * +

Ethnicity *

What other languages do you speak besides English?

Have you used or been known
by any other name(s)? *

Yes

No

If Yes, please provide other names (include maiden name): *

Please select from the list below which pertains to you. *

I've had a positive COVID-19 test

I've had a negative COVID-19 test

I've had a COVID-19 #1 Vaccine

I've had a COVID-19 #2 Vaccine

I've had a COVID-19 Booster #1

I've had a Flu Shot within the last 12 months

I've had none of the above

Transporation

Do you have a reliable car? *

Yes

No

Make & Model (Nissan Ultima): *

Which do you have? *

Drivers License

ID Card

State Issued: *

Driver's License Number: *

Expiration Date (MM-DD-YYYY) * +

ID Card Number: *

Expiration Date (MM-DD-YYYY) * +

Automobile Insurance Company Name: *

Expiration Date (MM-DD-YYYY) * +

Emergency Contact Information

*

	Name:	Relationship:	Cell Phone:	Home Phone:
-	Name:	Relationship:	Cell Phone:	Home Phone:

	Name:	Relationship:	Cell Phone:	Home Phone:
-	Name:	Relationship:	Cell Phone:	Home Phone:

	Name:	Relationship:	Cell Phone:	Home Phone:
-	Name:	Relationship:	Cell Phone:	Home Phone:

Position & Availability

Position Applying For *

How did you hear about us?

Are you legally authorized to work in the United States? *

Yes

No

Have you ever been charged or convicted of a Misdemeanor or Felony? *

Yes

No

If yes, please explain.

Desired Schedule & Days Available (Add times)

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Daytime	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Evening	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Night	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Overnight	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
24 Hr. Live-In	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday

Education

High School

City/State/Zip:

Diploma *

College:

City/State/Zip:

Completed Degree?

License/Certifications

CNA Certified *

Yes

No

Certification Number

State Issued

Expiration Date (MM-DD-YYYY) +

CPR Certified *

Yes

No

State Issued

Expiration Date (MM-DD-YYYY) +

Experience

Skill Assessment: Are you able or willing to perform these home care tasks/duties? *

	Yes	No
Ambulation	Yes	No
Are you able to safely lift 60 pounds?	Yes	No
Are you ok with a client that smokes?	Yes	No
Assist with Eating	Yes	No
Bathing	Yes	No
Diaper Change	Yes	No
Experience with Dementia	Yes	No
Experience with Gait Belt	Yes	No
Experience with Hospice	Yes	No
Experience with Hoyer LIft	Yes	No
Experience with Incontinence	Yes	No
Experience with Oxygen	Yes	No
Experience emptying and changing a Colostomy Bag	Yes	No
Experience with emptying and changing a Foley Catheter bag	Yes	No
Grooming	Yes	No
Housework	Yes	No
Laundry	Yes	No
Meal Preparation	Yes	No
Medication Reminders	Yes	No
Ok with Cats	Yes	No
Ok with Dogs	Yes	No
Personal Hygiene	Yes	No
Positioning	Yes	No
Shopping/Errands	Yes	No
Smart Phone to use for client documentation	Yes	No
Supervision/Companionship	Yes	No
Telephone Assistance	Yes	No
Toileting	Yes	No
Transferring	Yes	No

Employment History (must have at least 2 years experience with a facility or agency)

Employer 1

Company Name *

Address *

City *

State *

Zip Code *

Phone Number *

Start Date (MM-DD-YYYY) * +

End Date (MM-DD-YYYY) * +

Position *

Salary

Supervisor/Manager *

Reason for Leaving *

Employer 2

Company Name *

Address *

City *

State *

Zip Code *

Phone Number *

Start Date (MM-DD-YYYY) * +

End Date (MM-DD-YYYY) * +

Position *

Salary

Supervisor/Manager *

Reason for Leaving *

Employer 3

Company Name

Address

City

State

Zip Code

Phone Number

Start Date (MM-DD-YYYY) +

End Date (MM-DD-YYYY) +

Position

Salary

Supervisor/Manager

Reason for Leaving

Reference (cannot be a family member)

Name *

Address *

City, State, Zip *

Phone *

APPLICATION DISCLAIMER:

I certify with my signature below, that all statements made herein and on the enclosed resume are true and correct to the best of my knowledge. I authorize investigation of all statements herein recorded. I release from liability all persons and organizations reporting information required by this application.

Applicants Signature: *

clear

Date (MM-DD-YYYY) * +

PRE-EMPLOYMENT BACKGROUND CHECK AUTHORIZATION

I, understand that as part of the employment process, Texas Angels Home Health Care,
Inc. needs to complete a background check based on the information provided in the General Information section on me regarding:

Criminal Record;

Employee Misconduct Registry (EMR);

Nurse Aide Registry (NAR);

Sex and Violent Offenders Record;

Employment Verification;

Education Verification;

License Verification;

Motor Vehicle Records;

Reference Verification;

Drugs/Alcohol Testing;

I authorize all global, federal, and state agencies, including E-Verify check, persons, and organizations that may have information relevant to this research to disclose such information to Texas Angels Home Health Care, Inc. or its authorized agent (s).

I understand that this authorization is to be part of the written and signed employment application. I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.

I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law. I further authorize that a photocopy of this authorization may be considered as valid as the original.

I hereby certify that all statements on this form are true and correct to the best of my knowledge and belief. I understand that employment with Texas Angels Home Health Care, Inc. is contingent upon successful completion of a background check.

Full Name and Signature of Applicant Authorizing Release of Information:

First Name *

Middle Name *

Last Name *

Signature Authorization

clear

Date (MM-DD-YYYY) * +

Please submit a copy of your resume.