Employment Application

Promise Senior Solutions, LLC is an equal opportunity employer.

If you have uploaded a resume or applied on Indeed you only need to complete the required (*) in this application and sign electronically.

Name

First Name

Last Name

Date of Birth

MM/DD/YYYY

Social Security Number

Phone Number

Best Daytime Contact Number

Address

Mailing Address

Email Address

Emergency Contact

Emergency Contact Phone

License Type

Enter Professional License Information: TYPE / NUMBER / STATE / EXPIRATION

Additional Information

Check any that apply to you

TB Skin Test in the past 12 Months

Hep B Vacination

Legally Authorized to work in the USA

Able to pass pre-employment Drug Test

Convicted of a felony

Work Experience 1

Most recent work experience

Employer Name

Employer City / State

Supervisor Name

Employer Phone Number

Position Held

How Long With This Employer

Months or years - Please be Specific

Work Experience 2

Employer Name

Employer City / State

Supervisor Name

Employer Phone Number

Position Held

How Long With This Employer

Months or Years - Please be specific

Additional Information

Any additional License, Training, or Information Specific To The Position You Are Applying

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal. I give Promise Senior Solutions permission to use any information in this application to enable it and its agents to verify the information contained in this application. I also authorize present and former employers, educational institutions, credit agencies, references to answer all questions asked by Promise Senior Solutions with regard to subjects covered by this application. I understand that in connection with my application for employment Promise Senior Solutions will conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. This agency will check the employee misconduct registry (EMR). By signing this I understand that THHS applies absolute criminal bars to employment that are set out in the Texas Health and Safety Code, Chapter 250. I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee “at will” and employed for no definite period of time. I understand that either Promise Senior Solutions or I can terminate my employment at any time. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I have read the above and fully understand

Enter Last Name of Applicant

This will constitute your electronic signature

Enter Last Four of Social Security Number

This is to verify your electronic signature of this application.