Apply for CNA (Hospice) - In-Patient - Full Time - Days - Beaumont

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Summary
Title:CNA (Hospice) - In-Patient - Full Time - Days - Beaumont
ID:64459
Company:Harbor Hospice
Location:Beaumont, TX
Contact Information
* Salutation:
* First Name:
Enter your first name as shown on your Social Security Card
* Last Name:
Enter your last name as shown on your Social Security Card
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Last 4 Digits of Social Security Number:
Application Information
* How did you find out about this job?:
Please select the option that best describes how you found out about his job posting?
If Other:
If other, please list source in the blank above.
Opt-In Confirmation
I authorize recruiters from Harbor Healthcare System to send text messages from 8777806956 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
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Application for Employment
PERSONAL INFORMATION
* 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)?:

EMPLOYMENT DESIRED
* 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?:

EDUCATION
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

If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

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

EMPLOYER 1

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:
*

EMPLOYER 2

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:

EMPLOYER 3

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:

REFERENCES Please provide three references (not relatives).

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

EMPLOYABILITY STATEMENT AND AUTHORIZATION
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:
CNA - Texas - Hospice
* Are you currently licensed as a Certified Nursing Aide (CNA) in the State of Texas?:
Yes
No
* CNA License Number:
* Do you have any experience working as a Certified Nursing Aide (CNA)? If so, how many years?:
None
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
5+ years
* Do you have any experience working in the hospice and/or home health field? If so, how many years?:
None
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
5+ years
* Are you currently CPR Certified?:
Yes
No
* If yes, when does the certification expire?:

Please note: A physical copy of your CNA Certification Card is required for an interview.

Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond

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