Job Application
117 Hugo Street, Suite B, Kerrville, TX 78028
Licensed, 
Licensed & Certified & PAS
830-895-3100
800-506-5557
alindner.tchha@windstream.net

Who We Are
Eligibility
Obtaining Services
Who Pays
HIPAA Notice
Referral by Physician
Job Application
Private Pay Services

Member of:

Contact Information

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Choose one of the following positions to apply for:

Best time to contact you:

Work Status

Can you provide proof of your eligibility to work? Yes No

Have you ever filed an application with us before? Yes No

Have you ever been employed with us before? Yes No

Do any of your friends or relatives (other than spouse) work here? Yes No

Are you currently employed? Yes No

May we contact your present or past employers? Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No

Date available for work: -- dd/mm/yy

Desired salary range (per hour):

Are you available to work: 

Full-Time  Part-Time  Temporary

Are you currently on "lay off" status and subject to recall? Yes No

Can you travel if a job requires it? Yes No

Do you have a current CPR certification? Yes No

Education and Training

Elementary School (Name and address, course of study, number of years completed, diploma)?


High School (Name and address, courses of study, number of years, diploma)?


Undergraduate College (Name and address, courses of study, number of years, diploma) ?


Graduate Professional (Name and address, courses of study, number of years, diploma) ?


Other Education (Name and address, courses of study, number of years, diploma) ?


Describe any specialized training, apprenticeship, skills, and extra-curricular activities :


Describe any job-related training received in the US military :


Work History

Employer 1

Employer:
Address:
Telephone Number:
Job title:
Supervisor:
Reason for leaving:
Work performed:
Hourly Rate: 
Date Employed From: -- mm/dd/yy
Date Employed To: -- mm/dd/yy

Employer 2

Employer:
Address:
Telephone Number:
Job title:
Supervisor:
Reason for leaving:
Work performed:
Hourly Rate: 
Date Employed From: -- mm/dd/yy
Date Employed To: -- mm/dd/yy

Employer 3

Employer:
Address:
Telephone Number:
Job title:
Supervisor:
Reason for leaving:
Work performed:
Hourly Rate: 
Date Employed From: -- mm/dd/yy
Date Employed To: -- mm/dd/yy

Additional Information

List professional, trade, business, or civic activities and offices held (exclude membership which would reveal gender, race, religion, national origin, age, disability, or other protected status) :


Other Qualifications :


Any additional information that may be helpful :


References

Reference 1

Name:
Phone:
Address:

Reference 2

Name:
Phone:
Address:

Reference 3

Name:
Phone:
Address:

 

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Copyright � 2009 Tri County Home Health
Last modified: March 18, 2011