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 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.

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.

Today's Date (Month/Day/Year)  
How did you learn of this opening?
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 Code
  
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?

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

Pay Expected $ per 

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, 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   

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 
                                         
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 
                                         
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 
                                         
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

If yes, what job and why?

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

If yes, please explain, including date of conviction: 

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.

Name Address Phone Number Relationship Years Known
         
         
         

“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.

For electronic submission:

Do you agree to the terms outlined in this Employment Application?
Yes   No    

Name:

Date: (mm/dd/yy)

Submission of this application electronically constitutes legal signature of applicant

Please feel free to Contact Us with any questions, comments, or problems regarding the functionality of this online application.

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