Employment Application

Employment Application

First Name:		Last Name:
Address:
Apt.		City:
State:		Zip:
Home Phone:		Daytime Phone:
Email Address:
Education
High School: (name)		Year Graduated:
Address:
Trade School or Certificate obtained:
Trade School (Name)
Address:
Current certification expires:
Previous Employment
(Most recent employment)
Name of Company:
Company Address:
Name of supervisor or Human Resource person:
Telephone:
Title or position you held:
Give a brief description of duties you performed:
(Most recent employment)
Name of Company:
Company Address:
Name of supervisor or Human Resource person:
Telephone:
Title or position you held:
Give a brief description of duties you performed:

Name of Company:
Company Address:
Name of supervisor or Human Resource person:
Telephone:
Title or position you held:
Give a brief description of duties you performed:

Are you a U.S. Citizen:	Yes	No
If no do you have immigration papers?	Yes	No Please be prepared to show this information.
Social Security Number:
Do you have transportation to and from work?	Yes	No
Do you own your own car?	Yes	No
Current automobile insurance:	Yes	No
Texas Drivers License:
It may be necessary for you to use your car to meet a residents doctor appointment. This may be an occasional request if resident director is unable to meet the appointment. (This is not a requirement for employment.)
All references will be called! Please give current information. Include daytime telephone numbers where references may be reached.
Name:
Address:
Telephone:
How long have you known this person:
How do you know this person?

Name:
Address:
Telephone:
How long have you known this person:
How do you know this person?

Name:
Address:
Telephone:
How long have you known this person:
How do you know this person?

Have you ever been convicted of elderly abuse:	Yes	No
If yes please describe the circumstances surrounding the charge, briefly:
Is there any other information or extended circumstance that may prevent you from being employed by Holden Hands Home?	Yes	No

I certify that the information given in this application is true and correct to the best of my knowledge. I understand that any information given in this application found to be untrue may be grounds for immediate termination.
Please have the following items with you during the interview.
CPR certification CNA certificate Immunization records Texas Drivers license and proof of Automobile Insurance Bond (If employed: 14 days will be allowed to obtain a bond; employer will reimburse the bond fee after employment probationary period expires). References
Thank you for your interest in Holden Hands Home. I look forward to meeting you and discussing how we can help each other further our professional and personal goals. If you should have further questions not answered during our meeting, feel free to contact me at linda@holdenhandshome.com Linda H. Richardson, BSN RN

Holden Hands Home
9090 Skillman
182A Box 259
Dallas, TX 75243

Phone: (214) 343-7446
Fax: (214) 342-8641
E-mail: linda@holdenhandshome.com