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Texas Employment Application Form Online

News Release: Total Home Health is coming to Lakeland and Stuart with physical offices soon. Please apply if you are interested in applying for positions within the office or as a field clinician.

Employment Application Form

Step 2: Complete Application


  Please complete the application form and click the Submit button upon completion.
  Your information is confidential and securely stored, please see our privacy policy for more information.
  If hired, you will be required to provide documented proof of the right to work in the United States.
  Applicants will be tested for illegal drugs.

* Indicates Required Field
 

PERSONAL INFORMATION

* First Name:     * Last Name:     Middle Name:

* Address:     * City:    * State: * Zip:   

* Phone:     Cell:     Fax:    

Email:     *Social Security (Last Four) XXX-XX

Location to work within * Position Applied For:

Referred by:     * Desired Salary:     * Min. Required Salary:

* Availability:
Monday    Tuesday    Wednesday    Thursday    Friday    Saturday    Sunday
* Hours Available:
EMPLOYMENT HISTORY
Provide the following information of your past and current employers/assignments/volunteer activities, starting with the most recent.

Most Recent Employer
* Employer's Name:      * Position Held/Job Title:
* Address:   * City:    * State:    * Zip:
* Telephone:      * From:      *To:
* Duties:

Previous Employer
Employer's Name:      Position Held/Job Title:
Address:   City:    State:    Zip:
Telephone:      From:      To:
Duties:

Next Previous Employer
Employer's Name:      Position Held/Job Title:
Address:   City:    State:    Zip:
Telephone:      From:      To:
Duties:
EDUCATIONAL BACKGROUND
List the last three (3) institutions (schools/colleges/universities) attended, starting with the most recent.

Most Recent Education
* Institution Name:     * Course Study / Degree:
Address:      * From:      * To:

Previous Education
Institution Name:     Course Study / Degree:
Address:      From:      To:

Next Previous Education
Institution Name:     Course Study / Degree:
Address:      From:      To:
SKILLS & QUALIFICATIONS
Summarize any special job-related skills and qualifications acquired from previous employment or other experiences:

REFERENCES - PERSONAL/PROFESSIONAL
Please list three (3) references we may contact. Do not include family members.

* Name:     * Telephone:     * Number of Years Known:

* Name:     * Telephone:     * Number of Years Known:

* Name:     * Telephone:     * Number of Years Known:

APPLICANT STATEMENT

I certify that all the information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that my information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) discharge me from the employer's service whenever it is discovered.

I expressly authorize, without reservation, the employer and its representatives or agents, to contact and obtain any information from all references (personal and professional), employers, public agencies, licensing authorities, professional license authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer and its representatives, agents or employees, for seeking and/or gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal laws.

I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to re-apply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice. The employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurance to the contrary and that no implied oral or written agreement contrary to the foregoing expressed language are valid unless they are in writing and signed by the employer's president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that Federal Immigration laws require me to complete and 1-9 form.

DO NOT SUBMIT UNTIL YOU HAVE READ AND AGREE TO THE APPLICANT STATEMENT LISTED ABOVE.

BY SUBMITTING MY APPLICATION I CERTIFY THAT I HAVE READ, FULLY UNDERSTAND AND ACCEPT ALL TERMS OF THE FOREGOING APPLICATION STATEMENT.


APPLICANT SIGNATURE Date:
(Your name between // /FIRST LAST/):

 

 


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