Medicall Home Health Services LLC
Application for Employment

Print or type. Fill out the application form completely; submit the application by clicking the Submit button. We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of Medicall Home Health Services LLC.

Applicant name:*

First Last

Date:*

Position Applying for:*

Salary Desired: $*

Address:*

Street Address

City:*

City State ZIP Code

Telephone #:*

Email*

DOB:*

Social Security #

Type of employment desired:*

full-time
part-time
temporary

Date you will be available to start work:*

Do you have any objection to working overtime if necessary?*

Yes
No

Can you travel if required by this position?*

Yes
No

Have you ever been previously employed by our organization?*

Yes
No

Can you submit proof of legal employment authorization and identity?*

Yes
No

Have you ever had a license and/or employment suspended and/or terminated?*

Yes
No

Have you ever been charged, convicted, or pleaded “no contest” to a crime?*

Yes
No

If yes, please explain (a conviction will not automatically bar employment)

Drivers license number (if driving is an essential job duty)

How were you referred to us?

Employment History:

Include all information from your past four employers starting with the most recent.

Employer:*

Position held:*

Address:*

Street Address City State / Province / Region

Telephone #:

Immediate supervisor and title:*

Dates employed:*

Salary:

Job summary:*

Reason for leaving:

Employment History:

Position held:

Address:

Street Address City State

Telephone #:

Immediate supervisor and title:

Dates employed:

Salary:

Job summary:

Reason for leaving:

Employment History

continued:

Employer:

First

Position held:

Address:

Street Address City State

Telephone #:

Immediate supervisor and title:

Dates employed:

Salary:

Job summary:

Reason for leaving:

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications:

Educational History

List school name and location, years completed, course of study, and any degrees earned:

High school:*

Date graduated*

College:

Date graduated:

Technical Training:

Date graduated:

References

List 3 references names, telephone numbers, and years known (do not include relatives):*

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED.

I hereby authorize Medicall Home Health Services to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, criminal justice agencies, and references. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, criminal history check, licenses and driving records. I also hereby release from liability Medicall Home Health Services and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

I understand that it is the policy of Medicall Home Health Services to provide a drug-free, healthful, and safe workplace.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or Medicall Home Health Services, can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

Medicall Home Health Services is an Equal Opportunity Employer. Medicall Home Health Services does not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.”

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I understand, if I am an unlicensed person and if I have direct patient/Client, contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check, and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable.

Release: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license status and my license history.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant signature:*

Date:*

Medicall Home Health Services LLC
320 Cheyenne Trl
Keller, TX 76248.
Office 817-380-1735

BACKGROUND CHECK AUTHORIZATION AND RELEASE FORM

I hereby authorize the facility or any affiliate of Medicall Home Health Services LLC, bearing this release to obtain any information from schools, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment.

I hereby release any individual, including record custodians, from any and all liability for damages or claims of whatever kind or nature, which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

I also understand that an offer of employment with Medicall Home Health Services LLC, will depend on the outcome of the criminal history record information. I further understand that if the results indicate that I was convicted of a felony or had an offense involving moral turpitude (including, but not limited to theft, rape, murder, swindling, and indecency with a minor) that I never disclosed or State of Texas criminal history check per TXH&SC 250.006. or TAC §93.3 and TxH&SC Chapter 253. that I never disclosed, will make me ineligible for hire with Medicall Home Health Services LLC background checks are based on the DOB,NAME AND SS# if required,.

Applicant signature:*

Date:*

The information requested below is necessary to obtain accurate criminal history record information. Please print or type.

Legal Name:*

First Middle Last

Drivers License #:

State:*

State

Name

This field is for validation purposes and should be left unchanged.

Employment Application Form

Medicall Home Health Services LLC Application for Employment

Employment History:

Employment History

Other Skills and Qualifications

Educational History

References

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED.

Medicall Home Health Services LLC 320 Cheyenne Trl Keller, TX 76248. Office 817-380-1735

BACKGROUND CHECK AUTHORIZATION AND RELEASE FORM

The information requested below is necessary to obtain accurate criminal history record information. Please print or type.

Medicall Home Health Services LLC
Application for Employment

Medicall Home Health Services LLC
320 Cheyenne Trl
Keller, TX 76248.
Office 817-380-1735