It is this agency’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, genetic information, sex, marital status, national origin, or disability


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NameIt is this agency’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, genetic information, sex, marital status, national origin, or disability
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TEXAS KIDS HOME THERAPY & NURSING

Application for Employment

It is this agency’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, genetic information, sex, marital status, national origin, or disability.

Applicant Name:

Click here to enter name.

Email address:

email@sample.com

Present address:

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City/ST/Zip

Click here to enter City/ST/Zip.

Home phone:

555-555-5555

Mobile phone:

555-555-5555

Social security number:

555-55-5555

Are you at least 18 years old?

☐Yes ☐ No




Position applying for:

☐Full Time

☐Part Time

☐Part Time per Visit

☐Pool

Shift: ☐Day ☐ Night

☐ Evening ☐ Weekend

Salary requirements:

Click to enter amount.

Date available:

Click to enter date

If you are not a US citizen, do you have the legal right to remain permanently in the US?

☐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 7 years?

☐ Yes ☐ No

If yes, please give date, place and nature of each such conviction:




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Are you presently charged with any violation of the law other than a traffic violation?

☐ Yes ☐ No

If yes, please give date, place and nature of each such conviction:




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Educational History

Type of school

Name & Location of School

Check Last Year Attended

Graduated

Degree

High School

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☐ 9 ☐ 10 ☐ 11 ☐ 12

Year

Diploma, GED

College

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☐ 1 ☐ 2 ☐ 3 ☐ 4

Year

B.A., B.S. etc

College

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☐ 1 ☐ 2 ☐ 3 ☐ 4

Year

B.A.,B.S. etc

Other

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From: yr To: yr

Year

Degree

List professional licenses and certifications you possess. Indicate type of license, number and state:

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List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, genetic information, sex, marital status, national origin or disability:

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List languages spoken other than English:

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List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc.:

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In case of emergency, notify:

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Relationship:

Relationship.

Out of state contact, if possible:

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Relationship:

Relationship.



NAME:

Applicant Name.




Work History

Please attach an additional sheet listing other work experience pertinent to the position for which you are applying if the space below is insufficient.




Company name:

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Starting date:

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Address:

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Departure date:

Click to enter date.

City/ST/Zip:

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Type of work:

☐ FT ☐ PT ☐ PRN ☐ Per visit

Phone number:

555-555-5555

Salary:

Click to enter amount

Supervisor’s Name:

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OK to contact supervisor?

☐ Yes ☐ No

Reason for leaving:

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Please describe your job title, responsibilities, and accomplishments:




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Company name:

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Starting date:

Click to enter date.

Address:

Click here to enter text.

Departure date:

Click to enter date.

City/ST/Zip:

Click here to enter text.

Type of work:

☐ FT ☐ PT ☐ PRN ☐ Per visit

Phone number:

Click here to enter text.

Salary:

Click here to enter amount

Supervisor’s Name:

Click here to enter text.

OK to contact supervisor?

☐ Yes ☐ No

Reason for leaving:

Click here to enter text.

Please describe your job title, responsibilities, and accomplishments:




Click here to enter text.






Company name:

Click here to enter text.

Starting date:

Click to enter date.

Address:

Click here to enter text.

Departure date:

Click to enter date.

City/ST/Zip:

Click here to enter text.

Type of work:

☐ FT ☐ PT ☐ PRN ☐ Per visit

Phone number:

Click here to enter text.

Salary:

Click here to enter amount

Supervisor’s Name:

Click here to enter text.

OK to contact supervisor?

☐ Yes ☐ No

Reason for leaving:

Click here to enter text.

Please describe your job title, responsibilities, and accomplishments:




Click here to enter text.


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