Denton Rehabilitation and Nursing Center Application for Employment Denton Rehabilitation and Nursing Center provides equal employment opportunities without regard to race, color, religion, sex, national origin, age, veteran status or any other reason protected by law.INSTRUCTIONS Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature on back of application. Check position applied for:(Required) Therapy Certified Nurse Aide Dietary Aide Dietary Cook Housekeeping Laundry LVN / GVN (Circle One) Maintenance Nurse Aide Training RN Other (specify) (specify)(Required) Shift preferred:(Required) Available Start Date:(Required) How did you learn of this job opening? (Check one)(Required) Employee Referral Name Newspaper Walk-in Career builder College, Trade School Other (Explain) Other (Explain)(Required) Personal DataName(Required) First Name Middle Name Last Name Telephone Number(Required)Address(Required) Present Street Address City State ZIP Code Social Security Number(Required) Are you 18 years of age or older? Yes No GeneralWere you ever employed here? No Yes When? Have you ever applied here before? No Yes When?(Required) Under what name were you employed or made application for employment?(Required) Have you ever been convicted, or plead guilty or no contest to a crime involving the abuse, neglect, or mistreatment of an individual? Yes No Have you ever been convicted, or plead guilty or no contest to any other felony or misdemeanor (except routine traffic violations)? A conviction will not necessarily disqualify you. Yes No Important: For purposes of employment with DRNC “convictions” include: confinement, paid fine, time served, placed on probation (including deferred adjudication) and court-ordered restitution.Offense(s)(Required) County(Required) Date(Required) MM slash DD slash YYYY Disposition(Required) EducationHigh School (or date GED completed)(Required) Highest Grade Completed Graduation Date MM slash DD slash YYYY City(Required) State(Required) College or University(Required) Highest Grade Completed(Required) Graduation Date(Required) MM slash DD slash YYYY City(Required) State(Required) College Major(Required) Degree(Required) Additional Educational and/or Vocational or Technical training Information : School Courses Taken Did You Complete? City State: SPECIAL QUALIFICATIONSTyping Speed Shorthand Speed Computer Dictaphone PBX Medical Terms Administrator license #(Required) State(Required) Expiration date(Required) MM slash DD slash YYYY RN license #(Required) State(Required) Expiration date(Required) MM slash DD slash YYYY LVN/LPN license #(Required) State(Required) Expiration date(Required) MM slash DD slash YYYY Other license(s) or certification(s) #(Required) State(Required) Expiration date(Required) MM slash DD slash YYYY WORK HISTORYList names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and ANY PERIOD OF UNEMPLOYMENT. If self-employed, give firm names and supply business references. PLEASE GIVE MONTH AND YEAR . Name of most recent employer(Required) Telephone(Required)Address(Required) Address City State ZIP / Postal Code Job title(Required) Dates of employment: from (mo./yr.)(Required) to: (mo./yr.)(Required) Starting pay(Required) Ending pay(Required) Supervisor(Required) Reason for leaving(Required) Duties(Required)Explain any gap in employment(Required) Is any additional information relative to change of name, use of assumed name, nickname or maiden name necessary to enable us to check your work record? If so, list: May we contact your present employer? Yes No Have you ever been fired from a job or asked to resign? Yes No Are you now or do you expect to be engaged in any other business or employment? Yes No If yes, please explain: In case of emergency notifyName(Required) Phone Number(Required) REFERENCESGive three references, not relatives or former employers. Name(Required) Address(Required) Occupation(Required) Phone(Required) AGREEMENTI certify that the statements made on this application are correct and complete to the best of my knowledge. I understand that false or misleading information may result in termination of employment. I authorize Denton Rehabilitation and Nursing Center to conduct a reference check, which includes former employers, law enforcement agencies, and licensing agencies so that a hiring decision may be made. I understand that employment is conditioned upon positive responses from my references and a satisfactory criminal background check. Former employers named on this application are authorized to give information about me and I release them from all liability for giving such information.I understand that, if employed, my status is that of an employee at will. I am free to terminate my employment at any time and I have no contractual right, expressed or implied, to remain in the employ of Denton Rehabilitation and Nursing Center.I agree to immediately notify Denton Rehabilitation and Nursing Center if I am 1) convicted of, 2) receive deferred adjudication in, or 3) otherwise plead guilty or no contest to a felony or any crime not considered a routine traffic violation, while my application is pending or during my period of employment if hired.Finally, I understand that all company property must be returned and any indebtedness to the company must be paid before my termination. I authorize the company to deduct from my final pay check(s) all money due and owing to the company. Signature(Required) Date(Required) MM slash DD slash YYYY This employer is subject to Section 503 and 504 of the Rehabilitation Act of 1973.NameThis field is for validation purposes and should be left unchanged.
