Date: 4/16/2014

Application Form

The Home Option - Texas

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location

Select Office Location:

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Personal Information

Number Question Effective Date Expiration Date
1 Social Security Number  
     
2 Are you over the age of 18? (required)  
     
3 Are you a US Citizen? (required)  
     
4 If not a US Citizen, do you have the legal right & necessary documents to work in the US?  
     

Section 2 - Employment Information

Number Question Effective Date Expiration Date
1 Position Desired  
     
2 Salary Requirement (required)  
     
3 Date Available for Work (required)  
     
4 Employment Type (required)  
 
 
5 Current Availablity (Days/Hours available for work) (required)  
     
6 Shift Preference (required)  
 
 
 
 
 
7 Available to work weekends? (required)  
     
8 Do you possess a valid driver's license? (required)  
     
9 Do you have your own transportation? (required)  
     
10 Have you ever applied here before? If yes, when? (required)  
     
11 How were you referred to us? (required)  
 
 
 
 
 
12 If referred by an employee of The Home Option, please provide their name.  
     

Section 3 - Education and Qualifications

Number Question Effective Date Expiration Date
1 Name of high school attended (required)  
     
2 Did you graduate from high school? (required)  
     
3 Name of college attended  
     
4 Did you graduate from college?  
     
5 List other schools or training attended  
 
6 Are you a Certified Nurse Aide? (required)  
     
7 Nurse Aide Registration Number (if applicable)  
     
8 Do you have a current CPR certification? (required)  
     
9 List any languages spoken in addition to English  
     
10 Can you perform all of the job related functions of the position for which you are applying? (required)  
     
11 If you can't perform all of the job related functions of the position, please explain.  
     
12 Why do you want to work for this agency?  
 

Section 4 - Employment History

Number Question Effective Date Expiration Date
1 Are you currently employed? (required)  
     
2 Current / Most Recent Employer (Name & Address) (required)  
     
2 Dates of Employment  
     
2 Employer Phone Number  
     
2 Job Title and Rate of Pay  
     
2 May we contact the employer?  
     
2 Reason for Leaving  
     
3 2. Previous Employer (Name & Address)  
     
3 Dates of Employment  
     
3 Employer Phone Number  
     
3 Job Title and Rate of Pay  
     
3 May we contact the employer?  
     
3 Reason for Leaving  
     
4 3. Previous Employer (Name & Address)  
     
4 Dates of Employment  
     
4 Employer Phone Number  
     
4 Job Title and Pay Rate  
     
4 May we contact the employer?  
     
4 Reason for Leaving  
     

Section 5 - Professional References

Number Question Effective Date Expiration Date
1 1. Reference Name and Phone Number  
     
1 How I know:  
     
1 Years Known:  
     
2 2. Reference Name and Phone Number  
     
2 How I know:  
     
2 Years Known:  
     
3 3. Reference Name and Phone Number  
     
3 How I Know:  
     
3 Years Known:  
     

Section 6 - Criminal Background Inquiry

Number Question Effective Date Expiration Date
1 Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime? (required)  
     
2 If yes, please explain:  
     

Section 7 - Emergency Contact Information

Number Question Effective Date Expiration Date
1 Emergency Contact Name and Phone Number  
     
2 Alternate Phone Number  
     
3 Relationship to you  
     
4 Address  
     

Section 8 - Electronic Signature

Number Question Effective Date Expiration Date
1 Applicant Signature (Please type your Full Name) (required)  
     
2 Date Completed (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.