EMPLOYMENT APPLICATION

1. Preferred Location (Choose all that apply): *

MAGNOLIA

CONROE

NAVASOTA

2. First Name

3. Last Name

4. Your Email Address *

5. Mobile Phone # *

6. Your Date of Birth

7. Do you have a valid driver's license? *

8. State and Driver's License #: *

Example: TX 12345678

9. Have you lived in a state other than Texas within the past five years of the date of completion of this form? *

9a. If yes, please list all states you have lived in other than Texas within the past five years: *

10. Position You're Applying For *

11. Your Shift Preferences (Choose all that apply): *

Days

Evenings

Overnights

Weekends

12. Date You Are Available To Start: *

13. Your Hourly Wage Requirements

14. If you are NOT a US Citizen, do you have you the legal right to remain permanently in the US? (Select N/A if not applicable.)

15. How did you hear about Seasons? *

15a. Name of Seasons Employee who Referred You? *

16. Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? *

17. Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years? (If Yes, please give date, place, and nature of each such conviction.) *

17a. Conviction Explanation: *

18. Have you graduated High School or have GED Equivalent? *

18a. Name & Location of High School:

19. Have you attended College? *

19a. Name & Location of College, Years attended and any degrees you received: *

20. List any professional licenses you possess. Indicate type of license, number, and state.

Example: TX CNA #123456789

21. List any memberships in professional organizations, honors or activities which you feel would enhance your application. (Excluding those that would indicate age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.)

22. List any talents or skills applicable to the position for which you are applying, including computer experience, typing speed, etc.

23. Have you worked in long term care facilities before?: *

24. What do you enjoy about working with seniors in the long term care industry?: *

25. Anything else you'd like us to know about you?

EMPLOYMENT HISTORY

26. Name of Current or Previous Employer: *

Street Address

City

State

Phone Number *

Supervisor's Name: *

Date You Started: *

Date You Left:

Your Reason for Leaving: *

Is it OK to contact your supervisor? *

PERSONAL REFERENCES

Reference #1: *

Example: John Smith, Father

Reference #1 Phone Number: *

Example: 123-456-7890

Reference #2 *

Example: Lisa Waverly, Friend

Reference #2 Phone Number: *

Reference #3 *

Reference #3 Phone Number:

License & Consent

Please Upload your driver's license *

Take a picture of your license and upload it here.

I acknowledge that all Seasons locations are non-smoking facilities and I understand that I may not smoke anywhere on the grounds or in the building. Not adhering to this policy could result in immediate termination. I agree to follow this policy.

I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

I understand and agree that if I am offered employment by the facility, any employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility.

I understand, if I am an unlicensed person who has face-to-face resident/client contact, that the agency will perform a criminal history check per State Regulations as well as 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 HHSC-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 & Human Services Commission (HHSC) 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 formal hearing before the finding is placed on the registry; 3) All HHSC-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.

EMPLOYMENT APPLICATION

SUBMIT APPLICATION