ApplicationKyle Henderson2020-06-16T06:23:10-05:00 Career Application If you are dedicated, licensed, and qualified to be a healthcare service provider, then we would be very glad if you would join our family. We will welcome you with arms wide open. Just fill out the form below and we will get in touch with you in the soonest time possible. 1 Personal2 Education3 General4 Employment5 References6 Confirmation Name* First Middle Last Email* Gender*MaleFemaleHome Phone*Day Phone*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number*Position(s) Desired*Annual Salary Expected*Availability* Full Time Part Time Preferred Hours*7am-3pm3pm-11pm11pm-7amDaysEveningsNightsWeekendsDate Available for Work*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referral*How were you referred to us? Levels of Education* Elementary High School College Other Military Check all levels of education you have (regardless of whether or not you graduated).Elementary EducationSchool Name*Did you graduate?*YesNoGraduation Year*High SchoolSchool Name*School Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you graduate?*YesNoGraduation Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberGraduation Year*Diplomas & Degrees*Please list all diplomas or degrees.CollegeSchool Name*Course of Study*School Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you graduate?*YesNoGraduation Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberGraduation Year*Diplomas & Degrees*Please list all diplomas or degrees.OtherSchool Name*Course of Study*School Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you graduate?*YesNoGraduation Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberGraduation Year*Diplomas & Degrees*Please list all diplomas or degrees.MilitaryBranch of Service*Highest Rank*Course of Study*School Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Did you graduate?*YesNoGraduation Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberGraduation Year*Diplomas & Degrees*Please list all diplomas or degrees. General InformationHave you worked with us before?*YesNoWhen did you work with us?*Are you currently employed?*YesNoList reason for application*Are you legally eligible for employment?*YesNoHave you ever been convicted of a misdemeanor or a felony offense other than a minor traffic violation within the last 10 years?*YesNoPlease list nature, time, place and disposition of case.*Do you have a valid Texas Drivers License?*YesNoDriver License NumberAre you now Licensed or Certified in a professional or trade?*YesNoLicense Type*LVNRNPASNALicense State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number*License Expiration Year* Employers*Company NameCompany AddressType of BusinessEmployer PhoneStart DateEnd DateStart SalaryEnd SalaryDuties & ResponsibilitiesSupervisor NameSupervisor PhoneMay we contact?Reason for leaving Want to add more past employers?Use the + button above and to the right to add more past employers, up to 4. References*NameEmailPhone Want to add more references?Use the + button above and to the right to add more references, up to 4. Outstanding Professional or Practice Issues BNE Medicaid Medicare Other Do you have any outstanding professional or practice issues with any of the following?Please Explain*Please Explain Outstanding Professional or Practice IssuesMedical Conditions*YesNoDo you have any medical conditions, OR are you using any medications that may affect your performance on the job for which you are applying for?Please ExplainPlease explain medical issues.Final Statement I certify that the statements and information contained herein are true, complete, and correct to the best of my knowledge, and I authorize any former employer to release to this employer or its authorized representative any and all employment records and other information it may have about my employment. I understand that the information will be used for the purpose of evaluating my application for employment and that I am responsible for providing legal documents verifying my identity and eligibility for employment. In addition, I understand that, if selected for an interview, true copies of all degrees, certificates, or licenses listed on this application may be required before and employment decision can be made. A photocopy of this authorization shall be as valid as the original. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time, and the intentional misrepresentation of or failure to disclose information regarding my qualifications on my application or during the interview process will subject me to immediate discharge.Agreement* I Agree Check the box to signify that you understand and agree with the above statement.Date Applied Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.