The Gardens of Richardson

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1 The Gardens of Richardson 1111 West Shore Drive, Richardson, TX , APPLICATION FOR EMPLOYMENT Thank you for your interest in employment with The Gardens of Richardson. Please thoroughly read and complete the application form, and sign the Applicant s Acknowledgement & Authorization on page 4. Your application will be reviewed and we will contact you, if selected to participate in the interview process. This application will remain active for sixty (60) days following the application date. The Gardens of Richardson is committed to a policy of Equal Employment Opportunity and will not discriminate against applicants and employees on the basis of race, color, creed, religion, sex, age, national origin, ancestry, citizenship, sexual orientation, veteran status, physical or mental handicap or disability, or any other classification protected under federal, state, or local laws, regulations, or ordinances. Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are usually done which will ensure an equal employment opportunity without imposing undue hardship on The Gardens of Richardson. Please inform the company s Human Resources Representative if you need assistance completing any forms or to otherwise participate in the application process. PERSONAL INFORMATION Last Name First Name Middle Date 1 List any other names you have worked under: Home Phone: Cell Phone: List cities/states you have lived for the past seven (7) years: Have you ever worked for, or applied for a position at The Gardens of Richardson? No Applied Worked Name of position: When: Reason for leaving (if applicable): Has any member of your family worked for, or is currently employed with this company? Yes No If so, who and when? Are you under 18 years of age? Yes No Are you legally eligible to work in the United States? Yes No TELL US ABOUT THE POSITION YOU ARE APPLYING FOR Name of Position: Full-time Part-time PRN (scheduled as needed) Seasonal Temporary Minimum Income Requirement: $ Per Hour $ Per Year Please indicate the days and hours you are available to work. What date would you be available to begin work? Monday Tuesday Wednesday Thursday Friday Saturday Sunday a.m. a.m. a.m. a.m. a.m. a.m. a.m. p.m. p.m. p.m. p.m. p.m. p.m. p.m. Are you available to work nights, weekends, rotating shifts and holidays? Yes No How did you hear about this position? Walk-in Current/Former Employee (Name ) Advertisement ( Career Builder, Indeed.com, Newspaper) Other

2 2 High School: TELL US ABOUT YOUR EDUCATION Name of School, City & State Course of Study Years Completed Graduated Yes or No Degree or Diploma GED College: Graduate School: Trade or Business School: PLEASE NOTE: You MUST complete the employment history information even if you are attaching a resume. Please explain any gaps in employment. Please include other relevant volunteer or employment experience and dates on a separate piece of paper if needed. TELL US ABOUT YOUR EMPLOYMENT EXPERIENCE (Please start with the most recent work experience) TELL US ABOUT YOUR EMPLOYMENT EXPERIENCE TELL US ABOUT YOUR EMPLOYMENT EXPERIENCE (continues on next page)

3 3 TELL US ABOUT YOUR EMPLOYMENT EXPERIENCE TELL US ABOUT YOUR MILITARY EXPERIENCE Describe your duties and special training: Period of Active Duty: From: / / To: / / Date of final discharge: / / OTHER SKILLS, LICENSES, CERTIFICATIONS List other special skills/abilities you have that you feel would be an asset to The Gardens of Richardson (i.e. professional certifications/training, computer skills, foreign language, etc.): Applicants with certifications and licenses MUST also complete the Certification/License Verification form. Name of Reference Title/Relationship to Applicant OTHER REFERENCES Time Period under their supervision/time Period Known Phone Number

4 4 APPLICANT S ACKNOWLEDGMENT & AUTHORIZATION I understand that The Gardens of Richardson will check the references provided in this application and/or attached resume, including my former employers, supervisors, and schools. I authorize these individuals, companies and institutions to furnish The Gardens of Richardson with any information they have about me, and I release and hold them and The Gardens of Richardson harmless from any liability or damage whatsoever with respect to the release, or use of this information. Dependent upon state requirements, I understand I will be required to submit other background related information so that various background checks can be conducted, including, but not limited to: criminal history, finger-print clearance, proof of licensure, etc. I understand that if I am selected for hire (or receive an offer of employment); I may be required to submit to a postaccident, reasonable cause or random drug and alcohol test, as a condition of employment in accordance with applicable state laws. I authorize The Gardens of Richardson to have access to this information. If I am hired by The Gardens of Richardson, I agree to comply with all company policies, procedures, and management directives. I will be given and asked to read a copy of the Employee Handbook, which is a compilation of current policies, not an employment contract, which can be changed at any time, with or without notice. Employees of The Gardens of Richardson will be asked to sign the Acknowledgment of Receipt of Handbook. I will also be asked to produce a driver s license, social security card, or other documents proving my identity and right to work in the United States. I attest that all information disclosed on this application is true and accurate without omissions of any kind. I understand failure to meet these standards could impact my employment status, up to and including termination. I acknowledge and understand that my employment with The Gardens of Richardson is at-will and can be terminated by me or the company at any time and that no one has the authority to make exceptions to this at-will rule except in a written agreement signed by the owner of the company. SIGNATURE OF APPLICANT: PRINTED NAME: DATE: The Gardens of Richardson 1111 West Shore Drive, Richardson, TX , THIS SECTION TO BE COMPLETED BY PERSON PROVIDING THE REFERENCE Please provide the necessary reference request for the following current/former employee: Name of current/former employer: Telephone: City: State Position Held: Dates Employed: / / to / / Salary: $ How would you describe this applicant s performance? How would you describe this applicant s ability to work in a team? What would you say are the applicant s strengths? What are the applicant s opportunities for development? How would you describe this applicant s attendance? Would you rehire this employee? Yes No Signature of person completing the reference: Title: Date: TO BE COMPLETED BY THE GARDENS OF RICHARDSON HR REPRESENTATIVE Copies of this authorization form can be given to all references for completion. Reference verified by(facility representative): Date:

5 5 EMPLOYEE MISCONDUCT REGISTRY/NURSE AIDE REGISTRY Certification/License Verification Printed Name: Social Security Number: The State of Texas prohibits the hiring of an individual who is listed in the Employee Misconduct Registry and the Nurse Aide Registry as having abused, neglected, or exploited a resident/consumer of a facility or misappropriated a resident s/consumer s property. Before you are hired, your name will be checked against the State of Texas Employee Misconduct Registry and the Nurse Aide Registry. If you are listed on either of these registries, you are ineligible for employment. Indicate whether you are a: RN LVN CMA CNA Other certification/license: Certification/License Number: I understand that my name will be checked and certified that I have not been listed as having abused, neglected, or exploited a resident/consumer of a facility or misappropriated a resident s/consumer s property. I understand that my name, certification/license number, and status of my certification/license will be verified through the appropriate board or agency, and I certify that the above information is true and correct. Signature: Date: *OFFICE USE ONLY* CERTIFICATION/LICENSE VERIFICATION FORM Registered Nurse, Licensed Vocational Nurse, Certified Medication Aide, Certified Nursing Assistant All other certifications/licenses For Registered Nurses (RN) contact Registered Nurse Board (512) For Licensed Vocational Nurses (LVN) contact the Board of Vocational Nurse Examiners (512) For Certified Medication Aide (CMA) contact the Credentialing Department (800) Employee Misconduct Registry (ALL Applicants/Employees)/Nurse Aide Registry Check (800) both registries Certification/License Verification, if applicable (mark one) Applicant s certification/license is clear/current, and expires on: Applicant s certification/license is not clear due to: Applicant s license is not current and expired on: Applicant s license is unable to be verified. Employee Misconduct Registry (mark one) Employee is not listed on the Employee Misconduct Registry: Employee is listed on the Employee Misconduct Registry as unemployable: Nurse Aide Registry, if applicable (mark one) Employee is not listed on the Nurse Aide Registry: Employee is listed on the Nurse Aide Registry and is employable (complete Nursing Aide Certification information above): Employee is listed on the Nurse Aide Registry as unemployable: Information verified by: Date:

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