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 contact jobs@firstcarehomehealth.com - 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.

Today's Date (Month/Day/Year)         

How did you learn of this opening?      College Recruiting Job Fair Internet Newspaper Ad Agency Employee Referral

At which College, Career Fair, Ad, Etc (If any) did you hear about us?  

Referral - Who (If anybody) referred you?   

PERSONAL INFORMATION

Full Legal Name as it appears on your social security card

First Name         

Middle Name      

Last Name         

Social Security Number   

E-Mail Address   

Present Address

Street Address             City    

State        ZIP              Telephone Number    

Cell Phone Number 

Permanent Address

Check if same as present address

Street Address           City   

State       ZIP           Telephone Number  

Drivers Licensed         

State Issued      

Exp. Date         

Are you legally authorized to work in the United States?  (Select One)  Yes     No

For what type of position are you applying?

Full-Time-RN Part-Time-RN Case-Management-RN Full-Time-Field-LVN Part-Time-Field-LVN Weekend-On-Call-Nurse Home-Health-Aide Certified-Nurses-Aide Home-Health-Attendant Administrative-Staff Receptionist Accounting-Staff Billing-Staff Full-Time High-School-Help Part-Time Temporary Intern Co-op Contract Other

Do you have any impairements, physical or mental, which could interfere with your ability to perform any assignment?
   Yes     No

Pay Expected       $ per  Year Hour Week

Date Available (Month/Day/Year)           

License/Certification #          

State Issued      

Expiration Date         

Are you currently employed?  (Select One)   Yes     No

If so, may we contact your present employer?

Yes     No

EDUCATION

High School

Name           

Location       

Did you graduate?  (Select One)  Yes      No

GPA            Leave blank if not applicable

Number of Years Completed    

Courses Taken or Degree received  (Select One)

College Prep Business Technical Other

College, Business, Technical, UL Military, or Graduate School #1

Name        

Location    

Did you graduate?  (Select One)  Yes      No

Year of graduation or expected graduation        (Please enter only the year)

College Status    Graduate Freshman Sophmore Junior Senior

GPA          Leave blank if not applicable

Number of Years Completed            

Type of Degree Received (BA, MBA, BS, PHD)       

Field of Study (Business, IT, Engineering)    

College, Business, Technical, UL Military, or Graduate School #2

Name        

Location    

Did you graduate?  (Select One)  Yes      No

Year of graduation or expected graduation               (Please enter only the year)

GPA              Leave blank if not applicable

Number of Years Completed               

Type of Degree Received (BA, MBA, BS, PHD)       

Field of Study (Business, IT, Engineering)    

Trade Apprenticeship

Kind    

Company    

Number of Years      

Percent of college expenses earned    %

Hours worked per week while in school    

Type of work performed while in school    

WORK EXPERIENCE

Please begin with present employer.  Account for periods of unemployment of more than 30 consecutive days by listing “unemployed”
under “Employer Name”, and state beginning and ending dates of unemployment.  You must complete this section, even though you will
later be attaching a resume.

Employer #1

Employer Name        

Employer Address    

Type of business      

Phone Number         

Position Title             

Supervisor              

Work Status     Full-Time Part-Time Temporary Intern Co-op Contract Other
                            
Job Responsibilities/Duties    

Reason for leaving: Please explain   

 

Dates of Employment (mm/dd/yy) (Only enter a date - No additional text)

Start Date                                 End Date   

Starting wage $               (Please enter only a number - Example - "40,000" or "10.00")

Ending wage  $                (Please enter only a number - Example - "40,000" or "10.00")

Employer #2

Employer Name        

Employer Address    

Type of business      

Phone Number         

Position Title            

Supervisor              

Work Status     Full-Time Part-Time Temporary Intern Co-op Contract Other
                     
Job Responsibilities/Duties    

Reason for leaving: Please explain   

 

Dates of Employment (mm/dd/yy) (Only enter a date - No additional text)

Start Date                               End Date    

Starting wage   $            (Please enter only a number - Example - "40,000" or "10.00")

Ending wage     $           (Please enter only a number - Example - "40,000" or "10.00")

Employer #3

Employer Name         

Employer Address     

Type of business       

Phone Number          

Position Title             

Supervisor               

Work Status     Full-Time Part-Time Temporary Intern Co-op Contract Other
                                              
Job Responsibilities/Duties    

Reason for leaving: Please explain   

 

Dates of Employment (mm/dd/yy) (Only enter a date - No additional text)

Start Date                          End Date    

Starting wage   $      (Please enter only a number - Example - "40,000" or "10.00")

Ending wage     $       (Please enter only a number - Example - "40,000" or "10.00")

Employer #4

Employer Name       

Employer Address    

Type of Business     

Phone Number         

Position Title           

Supervisor             

Work Status             Full-Time Part-Time Temporary Intern Co-op Contract Other
                                         
Job Responsibilities/Duties    

Reason for leaving: Please explain   

 

Dates of Employment (mm/dd/yy) (Only enter a date - No additional text)

Start Date                             End Date     

Starting wage    $        (Please enter only a number - Example - "40,000" or "10.00")

Ending wage      $        (Please enter only a number - Example - "40,000" or "10.00")

Please indicate which employer(s) you DO NOT want contacted    

If ever employed or attended school under a different name, please provide that name  

Explain any gaps in work history

Are you planning to pursue or are you currently enrolled in any studies or courses?  (Select One)  Yes     No

If yes, when, where, for what period of time, or for what courses are you enrolled? 

If now employed, why do you want to change your job? (50 characters max)

Have you ever been fired, dismissed, asked to resign, resigned by mutual agreement, or otherwise been terminated from any job? (Select One)    

  Yes     No

Are you willing to travel?  (Select One)      Yes     No

Are you willing to relocate?  (Select One)     Yes     No

Have you completed any U.S. Military Service Active Duty?  (Select One)     Yes     No

Reserve or National Guard Obligation  (Select One)     Active     Inactive     None

Have you ever been convicted of any crime, other than a minor traffic offense (includes a “no contest” or “guilty” plea)?  Include any military
court-martials.  A yes answer will not necessarily disqualify you from employment  (Select One)  

  Yes      No

Are you currently under indictment or charged with a felony?  (Select One)     Yes     No

If yes, please explain    

Are you at least 18 years of age?  (Select One)     Yes     No

Do you have any friends or relatives currently employed by First Care Home Health or one of it’s satellite companies?  (Select One)     Yes     No 

If yes, indicate name and relationship    

List any additional skills, certifications, or abilities you would like to highlight (Start with most valued skill):

Skill # 1    

Skill # 2    

Skill # 3    

Skill # 4    

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

“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 and 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.