Careers – First Care Home Health

Employment Application

Application Instructions:
This application should be completed using our electronic application process. If for some reason you are unable to complete the application electronically, please Email Us or call us at 512.990.2425 and we will discuss alternatives for you.

Please be sure that all of your answers on this application are complete, correct, and truthful as the application will be verified. Any omission of information, any false or misleading statement, or any failure to disclose facts which, if known, might reflect unfavorably on this application, may result in dismissal even if you are employed.

Although this application may be given consideration, its receipt does not imply that there are open positions or that the applicant will be employed. First Care reserves its right to withdraw any offer of employment at any time; similarly the applicant has the right to withdraw this application at any time.

First Care Home Health is an equal opportunity employer and shall consider qualified applicants for all positions without regard to race, color, sex, religion, national origin, age, marital or veteran status, weight, height, non-disqualifying disability, or other legally protected characteristic. First Care Home Health will provide reasonable accommodation, upon request, for any qualified disability.

Step 1 of 5

Today's Date*
MM slash DD slash YYYY
How did you learn of this opening?*
At which College, Career Fair, Ad, Etc (If any) did you hear about us?*
Who Referred You?*
Name*
First Last
Email*
Phone*
Present Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Permanent Address (If Different From Present)
Street Address City State / Province / Region ZIP / Postal Code Country
IDENTIFICATION
Drivers Licensed*
State Issued*
Exp. Date*
MM slash DD slash YYYY
Are you legally authorized to work in the United States?*
- Yes
- No

References
For the purpose of reference checking, please provide the names, addresses, and relationships of three people not related to you, at least two of which were past supervisors.
Name (Ref 1)*
Address (Ref 1)*
Phone (Ref 1)*
Relationship (Ref 1)*
Years Known (Ref 1)*
Name (Ref 2)*
Address (Ref 2)*
Phone (Ref 2)*
Relationship (Ref 2)*
Years Known (Ref 2)*
Name (Ref 3)
Address (Ref 3)
Phone (Ref 3)
Relationship (Ref 3)
Years Known (Ref 3)
INFORMATION SUBMITTED
“I certify that all information submitted by me on this application is true and complete. That if any false information, omission, or misrepresentation are discovered, my application may be rejected and if I am employed my employment may be terminated at any time. In consideration of my employment, I agree to conform to FCHHS’s rules and regulations

I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time, at either my or the Company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice at any time by the Company. I understand that no Company representative, other than its President, and then only when in writing and signed by the President, has any authority to enter into agreement for employment for any specific period of time or to make any agreement contrary to the forgoing”.
FIRST CARE HOME HEALTH SERVICES APPLICATION FOR EMPLOYMENT
NON-DISCRIMINATORY POLICY:

PURPOSE:

1. To ensure compliance with the US Department of Health and Human Services Requirements

2. To ensure that the policy statement meets the DHS contractual requirements.

3. To incorporate the nondiscriminatory policy statement into the agency operating policies and procedures.

POLICY:

FIRST CARE HOME HEALTH SERVICES will conform to the Texas Department of Aging and Disability Services requirements for development and implementation of a nondiscriminatory policy statement.

FIRST CARE HOME HEALTH SERVICES will adopt the Texas Department of Aging and Disability Services requirements as outlined below:

NONDISCRIMINATORY POLICY: In accordance with Title VI of the Civil Right Act of 1964 and its implementing regulations, FIRST CARE HOME HEALTH SERVICES will not, directly or through contractual arrangements, discriminate on the basis of race, color or national origin in its admission or its provision of services and benefits, including assignments, transfers or referrals to or from the agency. Staff privileges are granted without regard to race, color, or national origin.

In accordance with Section 504 of the Rehabilitation Act of 1973 and its implementing regulation, FIRST CARE HOME HEALTH SERVICES will not, directly or through contractual arrangements, discriminate on the basis of disabilities in admission

I have read and understood the “Nondiscriminatory Policy” of FIRST CARE HOME HEALTH SERVIES.
Do you agree to the terms outlined in this Employment Application?
- Yes
- No
Name*
First Last

(Submission of this application electronically constitutes legal signature of applicant)
Please Note: In Order to Submit Your Application Online, You Must Agree to The Terms Outlined in This Employment Application
Comments
This field is for validation purposes and should be left unchanged.

Employment Application

Step 1 of 5

IDENTIFICATION

POSITION INFORMATION

SALARY INFORMATION

EDUCATION

WORK EXPERIENCE

References

INFORMATION SUBMITTED

FIRST CARE HOME HEALTH SERVICES APPLICATION FOR EMPLOYMENT

NON-DISCRIMINATORY POLICY:

Please Note: In Order to Submit Your Application Online, You Must Agree to The Terms Outlined in This Employment Application