* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):

Yes   No

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):

Yes   No

* Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last seven years? (A conviction will not necessarily result in the denial of employment):

Yes   No

If Yes, please explain:

* Have you ever worked for this Company before?:

Yes   No

If Yes, please provide details (Where/When/Job Title):

* Do you know personally of anyone currently or formerly employed by this Company or an affiliated company?:

Yes   No

* If Yes, please provide details (Who/Where/When/Job Title). If No, please respond N/A:

* Are you related to anyone currently or formerly employed by this Company or an affiliated company?:

Yes   No

* If Yes, please provide details (Who/Where/When/Job Title). If No, please respond N/A:

* Were you referred to this position by a current Harbor employee?:

Yes   No

If Yes, please provide the employee’s full name, job title, and site location.:

* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:

Yes   No

If no, please explain:

* Do you currently hold or have you ever been issued a state license for a clinical position? (This would include but is not limited to the following: CNA, LVN, LPN, RN, NP, MD, SW):

Yes   No

If yes, what type of state license(s)?:

Which state issued the license(s)?:

* When would you be available to begin work?:

* Type of employment desired:

Full-Time Part Time Seasonal

* Hourly rate/salary desired:

* Are you currently employed?:

Yes   No

If so may we inquire of your present employer?:

Yes   No

If presently employed, why are you considering leaving?:

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location	Did you Graduate?	Degree Received	Subjects Studied/Major
*	* Yes   No	*	*
	Yes   No
	Yes   No

Give your full employment record, starting with your current or most recent employment

Dates Employed	Employer Name & Address	Employer Phone
From: * To: *	* *	*
Job Title	Supervisor Name & Title	May we Contact?
*	* *	* Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
*	*	Start: * End: *

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

Dates Employed	Employer Name & Address	Employer Phone
From: To:
Job Title	Supervisor Name & Title	May we Contact?
		Yes No
Responsibilities	Reason for Leaving	Salary/Hourly Rate
		Start: End:

Name	Relationship	Phone Number	Email
*	*	*
*	*	*
*	*	*

I ACKNOWLEDGE THAT I HAVE BEEN INFORMED BY THE AGENCY THAT A STATE OF TEXAS CRIMINAL HISTORY CHECK WILL BE PERFORMED ON MY NAME AND MAY SEARCH THE NURSE AIDE REGISTRY AND THE EMPLOYEE MISCONDUCT REGISTRY. I HAVE INFORMED THE AGENCY OF ALL NAMES (I.E., MAIDEN, ALIASES) THAT I HAVE USED IN THE PAST. I HAVE NOT BEEN CONVICTED OF THE FOLLOWING CRIMES.

Arson
Assault
Assault - Aggravated
Assault - Sexual
Abandoning or Endangering a Child
Indecency with a Child
Injury to a Child
Burglary
Sale or Purchase of a Child
Injury to the Disabled
Injury to the Elderly
False Imprisonment
Homicide-Criminal
Aiding Suicide
Kidnapping/Abduct from Custody
Robbery
Robbery-Aggravated
Coercing, soliciting, or inducing gang membership
Misapplication of fiduciary property or property of a financial institution
Securing execution of a document by deception
Tampering with consumer product

IN ADDITION, I ACKNOWLEDGE THAT IF I AM FOUND TO HAVE BEEN CONVICTED OFAN OFFENSE UNDER CHAPTER 31, PENAL CODE OR ANY OTHER OFFENSE (S), THAT THESE MAY ALSO BAR MY EMPLOYMENT. THIS SWORN AFFADAVIT STATES THE UNDERSIGNED HAS NO CRIMINAL CONVICTIONS, IN TEXAS OR ANY OTHER STATE, OF AN OFFENSE.

TESTING

A battery of tests may be required of applicants before recommendation for employment. Individuals with a disability who require accommodations to take a required test should inform the tester in advance so accommodations can be made. A drug test is required and must be successfully completed before an employment offer is final. Your signature below indicates consent for this testing. Certain job classifications may require a medical examination after a conditional job offer has been made and before a potential employee begins work.

TOBACCO-FREE WORKPLACE

In the interest of providing a clean, safe, healthy, working environment, and promoting wellness among all employees, smoking and the use of all other tobacco products are not allowed in any The Agency building, parking, vehicle or on company time.

PLEASE REVIEW CAREFULLY BEFORE SIGNING STATEMENT BELOW

By my signature placed below, I affirm the information provided in this employment application is true and complete. I understand if employed, any false information or omissions shall be considered sufficient cause for dismissal without any obligation or liability to me other than for payment, at the rate agreed upon, for services actually rendered. I agree to immediately notify the Agency if I should be convicted of any crime while my job application is pending or during my period of employment, if hired.

I authorize the investigation of all statements contained in this application. I also authorize the company to contact my present employer (unless otherwise noted in this application form), past employers and listed references and other references that might know of my qualifications for employment.

I authorize any person, school, current employer (except as previous noted), past employer(s), physician(s), and organizations who might know of my qualifications for employment to provide the Agency with relevant information and opinions that may be useful to the Agency in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.

I understand before any employment offer is final, I will be given a drug test. My signature on this application gives consent for this drug test.

I understand and agree, if hired, that I may be required at anytime to a drug/alcohol test to determine if I am using or under the influence of drugs or alcohol. I also understand and agree, if hired, I may be required to submit to a search of my personal property for drugs, alcohol, weapons, or stolen property on the Agency’s property. If hired, I understand that if I become uninsurable, for purpose of driving a vehicle on company time, I may be immediately terminated.

I understand this application does not, by itself, create a contract of employment. I understand and agree, if hired, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF TIME, and may, regardless of the date of payment of my wages or salary, BE TERMINATED AT ANY TIME. I understand NO PERSON IS AUTHORIZED TO CHANGE ANY OF THE TERMS MENTIONED IN THIS EMPLOYMENT APPLICATION FORM.

This application will be retained for 6 months, and then destroyed. You may reapply if you so desire. If employed, this Employment Application will become part of your permanent file.

FULL SIGNATURE IS REQUIRED FOR APPLICATION TO BE CONSIDERED

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):

* Date: