PERSONAL INFORMATION

First Name *

Last Name *

Address

Street Address *

City *

State *

Country *

Postal code *

Email *

Phone *

Are you at least 18 years old? *

Yes

No

Do you have the legal right to work in the United States? *

Yes

No

Expected Rate of Pay? *

How soon are you able to start? *

Type of employment sought? *

Full Time

Part Time

Temporary

If part time, how many hours per week?

How did you learn about Texas Care? *

Are you related to anyone employed or supported by Texas Care?

Yes

No

If yes, please list their name, work location and relationship to you:

Have you applied for a job with us before? *

Yes

No

Have you ever worked for us before? *

Yes

No

If yes, please specify location:

Have you ever held a position of trust (handling money or confidential material)? *

Yes

No

Have you ever been listed by a Federal Agency as debarred, proposed for debarment or suspension, or otherwise excluded from Federal Medicare/Medicaid participation? *

Yes

No

If yes, please explain and notify the company representative assisting you with this application: *

Have you ever been convicted of, or have you ever pled guilty or no contest to, a felony offense? *

Yes

No

If yes, state conviction, date, and place where offense occurred: *

EDUCATION

High School (Name and Address) *

High School Graduate? *

Yes

No

College/University (Name and Address) *

Did you graduate? *

Yes

No

Degree/Major: *

Other Training/Education/Certifications/Licenses: *

What languages do you speak? *

PERSONAL REFERENCES

Must have known one reference at least five years. Do not list relatives as personal references.

1. Reference *

Name
Phone
Address
Length of Time Known

2. Reference *

Name
Phone
Address
Length of Time Known

3. Reference *

Name
Phone
Address
Length of Time Known

EMPLOYMENT HISTORY

Please fill it out completely. Do NOT state “See attached resume”.

Are you employed now? *

Yes

No

Why do you desire to make a change? *

Please describe all work experience beginning with the most recent:

Current/Most Recent Employer *

Name
Address
Phone #
Job Title / Duties
Immediate Supervisor Name & Position
Date Hired
Date Left
Starting Pay
Final Pay
Reason for leaving

Previous Employer *

Name
Address
Phone #
Job Title / Duties
Immediate Supervisor Name & Position
Date Hired
Date Left
Starting Pay
Final Pay
Reason For Leaving

In addition to your work history, what other experience, skills or qualifications do you believe would be beneficial to our company? *

DOCUMENT UPLOADS

Upload Recent Resume Here (All Applicants) *

Upload Recent Resume

Upload Transcripts (All Applicants) *

Upload Transcripts (All Applicants)

Upload Current Auto Liability Insurance (For QMHPs ONLY)

Upload Copy of Clinical Licensure (For Clinicians ONLY)

Upload Copy of Clinical Licensure

Upload Professional Liability Insurance (For Clinicians and QMHPs on 1099s ONLY)

For Clinicians and QMHPs on 1099s ONLY

EMERGENCY CONTACTS

I would like furnish Texas Care with my emergency contact information and authorize Texas Care and its representatives to contact any of the above on my behalf in the event of an emergency: *

Yes

No

Emergency Contact 1

Name
Relationship
Address
Phone
Email

Emergency Contact 2

Name
Relationship
Address
Phone
Email

Applicant’s Agreement and Certification *

I certify that facts set forth in this Application for Employment are true and complete to the best of my knowledge and that I completed the application myself. I understand that any false statements, omissions or misrepresentations may result in denial of employment or my dismissal, after employment. I authorize Texas Care Center, LLC to investigate any of my responses as set forth in this application and release the Company from any liability.

I understand that employment at Texas Care Center, LLC. is “at-will” which means that either I or the Company can terminate the employment relationship at any time with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis.

I understand that if a conditional offer of employment is made to me, it is conditioned upon my successful completion of a pre-employment drug testing, DMV and criminal background checks. I further understand that the company also performs medical examinations, post-accident, random, and for the cause drug testing throughout the course of employment in in accordance with state and federal law.

I understand that if employed, policies or procedures. In whole or in part may be revised, at any time and that I have an obligation to remain informed and seek clarification to the best of my ability.

I understand that this application will be active for the position I have applied for only, after which time I have to reapply in accordance with established company procedures.

I have applied for a position with Texas Care, LLC, I authorize all of my current and former employers to provide reference information, including my job performance, my work record and attendance, the reason (s) for leaving, my eligibility for rehire and my suitability for the position I am now seeking. I encourage my personal reference, current and former employers to provide complete response to requests for information, including information which is believed to be true but not documented. I realize some information may be complimentary and some may be critical.

I completed this application myself. I signed this release voluntarily and was not required to do so as part of the application process.

Employee / Contractor Signature *

Clear