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Employment Application

Personal Information

Date:
Name:     Email:
Social Security Number:  --
Name As It Appears on Driver's License:
Maiden Name: Any Other Names You've Used:
Date of Birth: --
Current Address:     City:      Zip:
Home Phone:      Cell Phone

Employment Record
Please list all employment experience. Begin with your present or last position and work back. Provide sufficient, qualifying experience.
Employer:
Position Title:
Address:
Ending Salary:
City: State:
Full-time Part-time
Start Date: End Date:
Months in this position:
Supervisor's Name:
Supervisor's Phone:
Reason for Leaving:
Responsibilities/Skills/Duties:
Employer:
Position Title:
Address:
Ending Salary:
City: State:
Full-time Part-time
Start Date: End Date:
Months in this position:
Supervisor's Name:
Supervisor's Phone:
Reason for Leaving:
Responsibilities/Skills/Duties:
Employer:
Position Title:
Address:
Ending Salary:
City: State:
Full-time Part-time
Start Date: End Date:
Months in this position:
Supervisor's Name:
Supervisor's Phone:
Reason for Leaving:
Responsibilities/Skills/Duties:
I hereby allow Heavenly Caregiver Services, Inc. to perform a check on my background, including the following as appropriate for the job opportunity in which I have expressed an interest.
  1. Criminal history check
  2. Driving record
  3. Past employment history
  4. Educational/professional status
  5. Personal references

I understand that a criminal history check is a requirement for employment with Heavenly Caregiver Services, Inc.'s home care programs.

I understand that certain information collected during the background check may exclude me from employment as listed below and that all information collected during the check will be kept confidential.

I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability for the job of homemaker/companion/personal attendant and such other, as they deem appropriate.

Convictions Barring Employment as listed in the Texas Department of Human Services Health and Safety Code Chapter 250:

  1. Criminal homicide
  2. Kidnapping and false imprisonment
  3. Indecency with a child
  4. Sexual assault
  5. Aggravated assault
  6. Injury to a child, elderly individual, or disabled individual
  7. Abandoning or endangering a child
  8. Aiding suicide
  9. Agreement to abduct from custody.
  10. Sale or purchase of a child.
  11. Arson.
  12. Robbery.
  13. Aggravated robbery.
  14. An offense that the agency determines to be a contraindication to employment with the consumers the agency serves.
  15. Assault.
  16. Burglary.
  17. Misapplication of fiduciary property or property of a financial institution.
  18. Securing execution of a document by deception.

Convictions Barring Employment per Heavenly Caregiver Services, Inc. policy:

  1. Theft
  2. More than one DWI or DUI
  3. Prostitution

Initial Here to Show Your Authorization to a Background Check

I certify that I have made no misrepresentation in this application and I have not withheld information in my statements and answers to questions. I hereby release HCGS to investigate and verify any representations made by me, either orally or in writing. I hereby release HCGS and any individual who provides or obtains information pursuant to this authorization, from any and all liability for damages of any kind which may result to me on account of compliance, or attempts to comply, with this authorization. I am aware that my misrepresentations may cause my application to be rejected or may cause dismissal if I am hired before such misrepresentations are discovered. I am also aware that my application is subject to the Texas open records law and may be released as a public document. I also understand that this application is the property of HCGS and will become a part of my personnel file if I am hired.
SIGNATURE OF APPLICANT:
DATE:
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