PERSONAL INFORMATION

EDUCATION/SKILLS

PROFESSIONAL LICENSES AND OR CERTIFICATES

CURRENT EMPLOYMENT

EMPLOYMENT HISTORY

Please provide three most recent employment histories.

REFERENCES

TRANSPORTATION

The following section must be completed if you are applying for a position that requires the operation of a motor vehicle, owned or leased by the agency, or if you must use your own vehicle for agency purposes.

TRAFFIC VIOLATIONS RECORD

List the traffic citations that you have received during the last five (5) years preceding date of this Application, and state the disposition of each, as "dismissed", "paid fine", "defensive driving", etc.

NOTE: If you are hired for a position that requires driving, you must keep us informed of Any changes in your driving record.

NOTICE TO PROSPECTIVE EMPLOYEES

Unified Rock Healthcare is an equal opportunity employer and complies with all federal and state laws pertaining to employment.

The health and safety code, Section 533.007, allows this agency to check conviction records of applicants. Certain convictions will disqualify you from employment.

Unified Rock Healthcare will check the background of all applicants to determine if the applicant has comfirmed allegation of abuse, neglect or exploitation and will not hire anyone with a confirmed case.

APPLICANT STATEMENT

By submiting this application, I certify that answers given herein on this application is true, correct and complete to the best of my knowledge. I also certify that I have accounted for all my work experience and training on this application, and I have not knowingly withheld any fact or circumstance, which I would have disclosed. Unified Rock Healthcare is hereby authorized to make any investigation of my employment, educational, credit or criminal history through any investigative agencies or bureaus of its choice. I release all relevant parties from all liability of any damages resulting from furnishing such information. I understand that I must be capable to perform the essential functions of the job for which I am applying. I understand that my employment is subject to mobility Evaluation and I understand that my employment may be conditioned upon maintaining a favorable drug/alcohol screening. I also agree that all information concerning said physical examination can be supplied to the authorized agent of this agency, upon request. If employed by Unified Rock Healthcare, I agree to abide by its rules and regulations. I understand discovery of misrepresentation or omission of facts herein will be cause for immediate dismissal. I authorize Unified Rock Healthcare to make any inquiry as required to complete my employment file. I understand that operating conditions may require me to temporarily or parmenently work shifts other than the one for which I am applying and I agree to such scheduling Changes as directed by my supervisor. I further understand that this application for employment is not an employment Contract. I Understand that if employed such employment is for an indefinite period and can be terminated at will by either party, with at least a two weeks notice in writing,at any time, for any or no reason, and is subject to change in wages, conditions, benefits, and operating policies. If employed, I will be required to complete an employment verification form and also show satisfactory evidence of identity and eligibility for employment within five days.