SISTERS OF GRACE HEALTH SERVICES, INC

AN INDUSTRY-LEADING MEDICAL STAFFING AGENCY IN HOUSTON, TEXAS

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Applicant

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EMPLOYMENT APPLICATION

All questions must be answered carefully and completely, regardless of attached resume or referral.

PERSONAL DATA

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Name *

Email *

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Date *

SS# *

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Phone *

Please list any other names you may have worked under:

Address

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City

State / Province / Region

Postal Code

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Date Available to start:

Additional Contact Number(i.e pager, business number):

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Classification:

RN
LVN
LVN( IV Cert)
CNA
EMT
Others

Please check (k) HOURS available:

7a-3a
3p-11p
11p-7a
7a-7p
7p-7a
Others

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Are You legally authorized to work in the United States?

Are you willing to work...?

Evenings
Weekends.

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How did you learn of our organization?

At
Agency
Other

Are You above the age of 18?

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Have you ever applied for employment with this Agency?

Are you legally eligible for employment in the United States?

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Do you have reliable transportation / the ability to reach multiple clients?

Can you perform the essential functions of the job for which you are applying with or without reasonable accommodation?

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Have you ever been convicted of a criminal offense ?

Where there any condition that prevented you from the working in acute facilities?

If yes, please explain:

Note: An affirmative answer will automatically disqualify you from being considered

Please list of referrals:

Please list of refferals:

Advertisement(Name of Publication):

School(Name of School):

Personal Referral(Name of Person):

Other(Please sepecify):

EDUCATION

Name of High School

Graduation (Month/Year)

Degree/Diploma

Name of College/University

Graduation (Month/Year)

Degree/Diploma

Other

Graduation (Month/Year)

Degree/Diploma

WORK HISTORY

All job must me recorded:use additional sheets if neccessary. List Most Recent work first.

Name of Institution *

Address *

Duties *

Immediate Supervisor *

Phone *

Dates Worked: From *

To: *

May we contact? *

Reason for leaving: *

Name of Institution

Address

Duties

Immediate Supervisor

Phone

Dates Worked: From

To:

May we contact?

Reason for leaving:

Name of Institution

Address

Duties

Immediate Supervisor

Phone

Dates Worked: From

To:

May we contact?

Reason for leaving:

Please include any other information you think would be helpful to SOG in considering your application, such as publications, activities, awards.etc.

In case of emergency, please notify:

Name *

Phone *

Relationship *

SISTER OF GRACE HEALTH SERVICES

APPLICATION FORM:

PLEASE EXPLAIN ANY GAP IN YOUR EMPLOYMENT HISTORY

FROM

REASON FROM LEAVING

PROFESSIONAL SKILLS

Li-censure

Licensure/Certification#: *

State: *

Exp.Date

Has your licence in any jurisdiction that you may have been licenced in ever been investigated , suspended or revoked?

If yes, please detail the circumstanced and the final outcome:

HEALTH CARE SPECIALITY:

Area:

Years Experience

Please indicate one of the following credentials you currently hold:

CPR/BLS Exp.Date:

ACLS Exp.Date:

NRP Exp.Date:

PALS Exp.Date:

NALS Exp.Date:

MAB Exp.Date:

REFERENCES

Reference Name: *

Occupation: *

Address: *

Phone: *

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Reference Name:

Occupation:

Address:

Phone:

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Reference Name:

Occupation:

Address:

Phone:

Emergency Contact Information

Please add 2 emergency contacts and medical contact information below.

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Emergency Contact #1 Name *

First

Last

Emergency Contact #1 Phone

Relationship to Emergency Contact #1

Emergency Contact #1 Email *

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Phone

Relationship to Emergency Contact #2

Emergency Contact #2 Email *

Medical Information

Physician Name *

First

Last

Emergency Contact #2 Phone

Preferred Hospital

Vaccination Information

PPD RESULTS UPLOAD

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Upload PPD RESULTS

PROOF OF COVID VACCINE UPLOAD

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Upload Proof of Covid Vaccine

AGREEMENT

(Please read the following statement carefully)

Name *

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Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Are you capable of performing the job set forth in the job description?

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CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

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Upload your resume

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Upload your cover letter

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1-9 Employment Eligibility Verification In order to be considered for employment you must fill out the USCIS Form I-9.

1. Go to this link https://www.uscis.gov/sites/default/file s/document/forms/i-9.pdf (this link will open in a new window)

2. Fill out the form online. (or print and fill out)

3. Download the completed PDF file. (or scan as PDF your completed form)

4. Attach the PDF file here ->

Form I-9 Upload

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I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

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authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

I authorize PartnerCare Health, LLC to use all state-approved portals for my background check and OIG exclusion list.

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Voided Check

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Please upload a voided check for direct deposit payment.

DocuSign

SISTERS OF GRACE HEALTH SERVICES, INC

AN INDUSTRY-LEADING MEDICAL STAFFING AGENCY IN HOUSTON, TEXAS

PowerForm Signer Information

Applicant

EMPLOYMENT APPLICATION

PERSONAL DATA

Note: An affirmative answer will automatically disqualify you from being considered

Please list of referrals:

Please list of refferals:

EDUCATION

WORK HISTORY

All job must me recorded:use additional sheets if neccessary. List Most Recent work first.

In case of emergency, please notify:

SISTER OF GRACE HEALTH SERVICES

APPLICATION FORM:

PLEASE EXPLAIN ANY GAP IN YOUR EMPLOYMENT HISTORY

PROFESSIONAL SKILLS

Li-censure

HEALTH CARE SPECIALITY:

Please indicate one of the following credentials you currently hold:

REFERENCES

Emergency Contact Information

Please add 2 emergency contacts and medical contact information below.

OCR Result(Auto-Detect)

Translated(English)

Medical Information

Vaccination Information

AGREEMENT

1-9 Employment Eligibility Verification In order to be considered for employment you must fill out the USCIS Form I-9.

1. Go to this link https://www.uscis.gov/sites/default/file s/document/forms/i-9.pdf (this link will open in a new window)

2. Fill out the form online. (or print and fill out)

3. Download the completed PDF file. (or scan as PDF your completed form)

4. Attach the PDF file here ->

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

I authorize PartnerCare Health, LLC to use all state-approved portals for my background check and OIG exclusion list.