Escolar Documentos
Profissional Documentos
Cultura Documentos
Date: _________________
Applicant: ____________________________________________
1.
2.
3.
4.
What did you like best about your past jobs (work style)?
5.
What did you like least about your past jobs (work style)?
6.
7.
8.
9.
!1
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com
Admin Assistant:
Do you have any policy/procedure experience?
Do you have experience with developing agendas, taking notes of meetings and preparing minutes for meetings?
Do you have any dictation/transcription experience?
Do you have any experience with creating/revising forms?
!2
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com
DATE
______________________________________
Name _______________________________________________________________________________________________
Last
First
Middle
Maiden
Street
City
State
Zip
How many hours can you work weekly? _________________________ Can you work nights? ________________________
Employment desired
{ }FULL-TIME ONLY
{ }PART-TIME ONLY
{ }FULL- OR PART-TIME
TYPE OF SCHOOL
NAME OF SCHOOL
LOCATION
(Complete mailing
address)
NUMBER OF YEARS
COMPLETED
High School
College
Professional School
{ } Yes
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation. ___________________________________________________
____________________________________________________________________________________________________
{ } Yes
{ } No
{ } Operator
{ } Commercial (CDL)
{ }Chauffeur
Have you had any moving violations during the past three years?
OFFICE ONLY
Typing
{ } Yes
{ } No
Personal
Computer
{ } Yes
{ } No
_____ WPM
PC
Mac
{ } Yes
10-key { } No
{}
{}
Word
Processing
{ } Yes
{ } No
_____ WPM
Other
__________________________________________________
Skills
__________________________________________________
Name
__________________________________________________
Position _______________________________________
Position
__________________________________________________
Company _____________________________________
Company
__________________________________________________
Address ______________________________________
Address
__________________________________________________
______________________________________
Telephone (
Telephone (
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the
space below to summarize any additional information necessary to describe your full qualifications for the specific position for
which you are applying.
{ } Yes
{ } No
{ } Yes
{ } No
Work
Experience
Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer
Address
Name of last
supervisor
Employment dates
Pay or salary
From
Start
To
Final
Name of employer
Address
Name of last
supervisor
Employment dates
Pay or salary
From
Start
To
Final
Please list your work experience for the past five years beginning with your most recent job held.
If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer
Address
Name of last
supervisor
Employment dates
Pay or salary
From
Start
To
Final
Name of employer
Address
Name of last
supervisor
Employment dates
Pay or salary
From
Start
To
Final
{ } Yes
{ } No
{ } Yes
{ } No
In exchange for the consideration of my job application by FAMILIA HEALTHCARE SERVICES (hereinafter
called the Company), I agree that:
Neither the acceptance of this application nor the subsequent entry into any type of employment relationship,
either in the position applied for or any other position, and regardless of the contents of employee
handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to
time, or other Company practices, shall serve to create an actual or implied contract of employment, or to
confer any right to remain an employee of FAMILIA HEALTHCARE SERVICES , or otherwise to change in
any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot
be altered except by a written instrument signed by the Administrator of the Company. Both the undersigned
and FAMILIA HEALTHCARE SERVICES may end the employment relationship at any time, without
specified notice or reason. If employed, I understand that the Company may unilaterally change or revise
their benefits, policies and procedures and such changes may include reduction in benefits.
I authorize investigation of all statements contained in this application. I understand that the
misrepresentation or omission of facts called for is cause for dismissal at any time without any previous
notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise
indicated), references, and others, and hereby release the Company from any liability as a result of such
contract.
I further understand that my employment with the Company shall be probationary for a period of sixty (60)
days, and further that at any time during the probationary period or thereafter, my employment relation with
the Company is terminable at will for any reason by either party.
I certify with my signature below that all information provided in this form is true and accurate.
Signature of applicant__________________________________________ Date: ___________________
Thank you for completing this application form and for your interest in our business.
I have received, have read and agree to the terms specified in this job description for the position I
presently hold. I further understand that this job description may be reviewed at any time and that I
will be provided with a revised copy.
Employee Signature
Date
STATEMENT OF EMPLOYABILITY
By execution of this document, I ______________________________,
hereby acknowledge that I have been informed by FAMILIA HEALTHCARE SERVICES that a criminal
history check will be performed on my name. I have informed this agency of all names (i.e., maiden
name, aliases) that I have used in the past. I understand that I have been employed on an emergency
basis and that my employment is temporary or interim pending the results of the criminal history
check.
I hereby profess that I have not been convicted of any of the following crimes which are a
permanent automatic bar to employment by this agency:
I also hereby profess that I have not been convicted of any of the following crimes within the
past 5 years (applicable only to those hired on or after September 1, 2007 unless otherwise
noted):
An offense under Section 22.01, Penal Code (assault punishable as a Class A Misdemeanor or felony)
[applicable to those hired on or after September 1, 2003];
An offense under Section 30.02, Penal Code (burglary) [applicable to those hired on or after September
1, 2003];
An offense under Chapter 31, Penal Code (theft punishable as a felony)[applicable to those hired on or
after September 1, 2001]
An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a
financial institution punishable as a Class A Misdemeanor or felony) [applicable to those hired on or after
September 1, 2003];
!1
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com
An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable
as a Class A misdemeanor or felony) [applicable to those hired on or after September 1, 2003];.
An offense under Section 37.12, Penal Code (false identification as peace officer); or
An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).
I understand that if I have been placed on deferred adjudication community supervision for an
offense listed above, successfully completed the period of deferred adjudication community
supervision, and received a dismissal and discharge according to Section 5(c), Article 42.12,
Code of Criminal Procedure, I am not considered convicted of that offense.
I acknowledge that if I am found to have been convicted of any other offense(s), that these
offenses may also bar my employment.
I understand that all information obtained by this agency regarding any criminal history will
remain confidential.
I certify that the information on this form contains no willful misrepresentation and that the
information given is true and complete to the best of my knowledge.
_____________________________________________
Signature of Applicant
_____________________________________________
Printed Name
_____________________________________________
Date
!2
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com
Very good_________
Satisfactory________
Unsatisfactory______
Please explain________________________________________________
Superiors__________
Co-workers________
Subordinates_______
Please explain________________________________________________
____________________________________________________________
I release FAMILIA HEALTHCARE SERVICES its officers, employees and agents from any and all
liability from the results and preparation of any reports concerning my background or myself. I
understand that a criminal history report will be requested from the Texas Department of Public
Safety Code 250.006.
I authorize FAMILIA HEALTHCARE SERVICES to submit a request for a Criminal History Check to
the Texas Department of Public Safety
Date:
Print Name:
Signature:
Maiden Name:
Date of Birth:
Race:
SS#:
Sex:
Acknowledgement Form
______________________________________
_________________
Date signed
Pre-Employment TB Questionnaire
To Be Completed by Employee:
Name: ______________________________________ SSN:_____________________
! Yes
! No
! Yes
! No
! Yes
! No
! Yes
! No
! Yes
! No
! Yes
! No
! Yes
! No
8.
! Yes
! No
Employee Signature:____________________________________________
Date:____________________
Tel: 844-767-2846 Fax: 855-450-2251 familiahealth@gmail.com
Page 1 of 1
TB AGREEMENT
Last Revised:
Adopted:
RV
IC
ES
LT
H
AR
SE
______________________
Instructor's Signature
EA
____________________
Employee Name
__________
Date
FA
M
IL
IA
_____________________
Employee Signature
INFECTION
!78
Page 1 of 1
Last Revised:
Adopted:
RV
IC
SELF-EMPLOYED CONTRACTOR
ES
AR
SE
I understand that due to my occupational exposure, or potential exposure, to blood and/or other
potentially infectious material, I may be at risk of acquiring Hepatitis B virus (HBV) infection. As
a self-employed contractor, I understand that it is my responsibility to be informed regarding the
risks (health and otherwise), disease process, exposure routes, prevention symptoms and
treatment of this disease. I understand that by declining this and treatment of this disease. I
understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a
serious disease. I hereby release the Agency from any and all liabilities arising from my
declination to be immunized.
LT
H
________________________________________________________________
SIGNATURE
FA
M
IL
IA
EA
_____________
DATE
INFECTION
!32