| Angelic Home Care Services in Texas

ANGELIC HEALTHCARE SERVICES INC

APPLICATION FOR EMPLOYMENT

Thank you for your interest in joining our team! Please fill out this form completely and accurately. All fields marked with (*) are required.

Employee Details

Employee Name

Title

Employment Status

Full-time Part-time

Hire Date

Start Date

Personal Information

All prospective employees will receive consideration without discrimination because of race, color, sex, age, natural origin, or handicap. All information provided here in will be kept confidential.

Last Name

First Name

Middle

Date

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Business Phone

SSN

Date of Birth

Emergency Contact (person not living with you)

Emergency Contact Phone

Have you ever applied for employment with the Agency?

Yes No

How many hours a week are you available for work? (Minimum )

How many hours a week are you available for work? (Maximum)

When will you be available for work?

Are you legally eligible for employment in the United States?

Yes No

How did you learn of our organization?

Newspaper Employee Other

Are you willing to work ?

Evenings Weekends

Was your last name different from your present one during the above listed jobs?

Yes No

If Yes, what was your name?

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

Do you have reliable transportation if required?

Yes No

Education

School Name

Location for School

Year Completed

Course of Study

Degree / Diploma College/ Vacational tech on Trade School/ High School/Other

Employment History

List the last 5 years of your employment history, starting with the most recent employer.

Company 1

Company Name

Telephone

Address

Dates of Employment From:

Name of Supervisor

Starting Pay

Ending Pay

Job Title and describe your work:

Reason for Leaving

Company 2

Company Name

Telephone

Address

Dates of Employment From:

Name of Supervisor

Starting Pay

Ending Pay

Job Title and describe your work:

Reason for Leaving

Company 3

Company Name

Telephone

Address

Dates of Employment From:

Name of Supervisor

Starting Pay

Ending Pay

Job Title and describe your work:

Reason for Leaving

Professional References

Persons who can furnish information about job performance.

Name

Telephone

Address

General

Have you been convicted of a crime in the past Syears, barring employment in a Home and Community support services Agency?

Yes No

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

Are you capable of performing the job duties set forth in the job description?

Yes No

If you answered No, which job requirements can you not meet?

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

Reference Verification

Name of the Applicant

Position

Name Of Reference

Reference Phone

Years Known

Date Veriifed

Signature

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I authorized complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing same to the Agency. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time. I, the undersigned understand all policies and procedures of the company and willing to comply and abide with all rules.

Signature

Date

Personal Attendants Pay Rate Notification

49.312
A contractor of this chapter must:
1. pay a personal attendant a base wage of at least $8.11 per hour; and
2. notify a person who becomes employed or contracts as a personal attendant within three days after the person accepts the offer of employment or enters into the contract that the contractor is required to pay the wage described in paragraph (1) of this subsection.
Pursuant to §49.312 this is to inform you that effective 09/01/2019 you will be paid a wage of $8.11 per hour.

Attendant Signature

Date

Salary/ Wage Agreement

Name of Employee

Hourly Base

Employee Initial

Employee Signature

Date

Human Resources Signature

Date

tick

I, an employee of ANGELIC HEALTHCARE SERVICES INC, acknowledge and agree that my salary with ANGELIC HEALTHCARE SERVICES INC

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Consent & Agreement