Application for Employment

We are an equal opportunity employer. All qualified applicants receive consideration without regard to race, color, religion, sex, national origin, disability, protected veteran status, or any other characteristic protected by law.

Call Now — 956-339-0311

For office use — prints a blank copy for an applicant to complete by hand.

Or complete the written application below

Your Information

Applicant nameCurrent addressCity / State / ZIPEmailPhoneAlternate phone (optional)

Social Security number Completed in person

Left blank online — a manager completes and signs this with you in person, then files the signed hard copy.

Eligibility

Are you at least 18 years old?YesNo

If not a U.S. citizen, do you have the legal right to remain permanently in the U.S.?YesNoN/A

Do you have reliable transportation, including on short notice?YesNo

Have you been convicted of a crime (excluding misdemeanors and traffic violations) in the past 7 years?YesNo

A background check is completed at onboarding for roles with direct patient contact. A prior conviction is not an automatic bar to employment.

Position

Position applying forCountyExpected rate of pay (optional)Date available (optional)

Education History (optional)

High School

Name & location of schoolLast year completedGraduatedDegree

College

Name & location of schoolLast year completedGraduatedDegree

Other

Name & location of schoolLast year completedGraduatedDegree

Professional licenses (type, number, state)

Languages & Skills (optional)

Languages spoken other than EnglishOther skills (computer, typing speed, etc.)

Employment History (optional)

Employer 1

Company nameSupervisor's nameCompany address / city / state / ZIPPhoneType of businessJob titleFirst working dayLast working dayRate of payResponsibilities / accomplishmentsReason for leaving

OK to contact this supervisor?YesNo

Employer 2

Company nameSupervisor's nameCompany address / city / state / ZIPPhoneType of businessJob titleFirst working dayLast working dayRate of payResponsibilities / accomplishmentsReason for leaving

OK to contact this supervisor?YesNo

Professional References (optional)

Reference 1

NameCompanyPhoneCity / State / ZIP

Reference 2

NameCompanyPhoneCity / State / ZIP

Review & CertifyI certify that the information provided in this application is true and complete to the best of my knowledge.I understand that, if hired, my employment is at-will and may be terminated by either party at any time, with or without cause or notice.

Typed full name (signature)Date

Background Check Authorization & Release Completed in person

I authorize Reigning Grace Primary Home Care, LLC to conduct a criminal background check and, where applicable, verify my employment and education history, as part of my application for employment. I understand this authorization does not guarantee employment and that background check results will be considered in a manner consistent with applicable law.

Signature

Date

Left blank online — a manager completes and signs this with you in person, then files the signed hard copy.