Have you ever been convicted of a misdemeanor involving theft?
  Yes   or   No

Have you ever been convicted of a misdemeanor involving abuse, neglect, or mistreatment of an individual?
  Yes   or   No

A conviction will not necessarily disqualify you. If you answered yes to any of the questions above, list convictions below.

Offense(s):
Date:
Place:
Disposition:

If you are under 18 years of age, can you provide proof of your eligibility to work?
  Yes   or   No   or   Not Applicable

If employed, can you provide documentation of your legal right to work in the United States?
  Yes   or   No

Desired Hours:

shift
Full-Time
Part-Time

Desired Job:

Desired Salary:

Date Available:

Are you employed now:

YES
NO
If so, may we inquire of your present employer?

YES
NO

Graduate School:

Name and location of school

Course of Study

Years completed

1   2   3   4

Degree or Diploma

College:

Name and location of school

Course of Study

Years completed

1   2   3   4

Degree or Diploma

Business/Trade/Technical:

Name and location of school

Course of Study

Years completed

1   2   3   4

Degree or Diploma

High School:

Name and location of school

Course of Study

Years completed
1   2   3   4

Degree or Diploma

Subject of Special Study or Research Work:

Job related skills (computers, driver's license, etc.):

Company name 1

From - To:

Salary:

Reason for leaving:

Telephone:

Company address:

Company City/State/Zip:

Company Supervisor name:

Job Title and description of your work:

Company name 2

From - To:

Salary:

Reason for leaving:

Telephone:

Company address:

Company City/State/Zip:

Company Supervisor name:

Job Title and description of your work:

Company name 3

From - To:

Salary:

Reason for leaving:

Telephone:

Company address:

Company City/State/Zip:

Company Supervisor name:

Job Title and description of your work:

Company name 4

From - To:

Salary:

Reason for leaving:

Telephone:

Company address:

Company City/State/Zip:

Company Supervisor name:

Job Title and description of your work:

Name 1:

Business:

Address:

City/State/Zip:

Telephone:

Name 2:

Business:

Address:

City/State/Zip:

Telephone:

Name 3:

Business:

Address:

City/State/Zip:

Telephone:

The information I have provided in this Application for Employment is true, correct and complete. False, incomplete, or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and obtain information about me from previous employers, educational institutions and "reference" I provide, and any other party necessary to verify the accuracy of information I disclosed in this application, related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in 60 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application.

This application is not an employment contract. I understand at Regent Care Centers is "at will" and that either the Company or I can terminate the employment relationship at any time, for any reason, with or without notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer.

Regent Care Centers is committed to providing a drug free workplace. Pre-employment, random, for cause and post-accident drug testing may be utilized to ensure out employees and residents are not at risk and I understand that, if hired, I will be required to acknowledge Regent Care Center's Drug Policy and Procedure and must agree to be bound by such Policy and Procedure.

I further understand that Regent Care Center will conduct a Criminal History Check, Employee Misconduct Registry Check, Nurse Aide Registry Check, and if applicable, a licensure check. I understand that I will be required to consent to such checks and that my failure or refusal to consent to such checks now or in the future will result in my being ineligible for employment or termination of employment if already employed with Regent Care Center.

By writting I AGREE in this box, I have read and fully understand and accept all terms and conditions in the above statement.

Date

Print name

How did you hear about us

Newspaper - if so which one:
Friend
Employee Referral - if so which one:
CareerBuilder.com
HoustonJobs.com
AustinJobs.com
CityofHouston.com
Other - if so which one: