Employment Application Employment Application Step 1 of 7 14% Dependable Health Services is an equal opportunity and affirmative action employer. Dependable Health Services does not discriminate against qualified applicants or employees on account of race, color, sex, age, religion, national origin, physical or mental disability, veteran status or other protected categories under federal and state laws, regulations and local ordinances. Dependable Health Services prohibits any form of workplace harassment. Application Instructions: Please provide full and complete information. For questions which do not apply to you, please write “N/A” (Not Applicable). You may supplement the completed application with a resume, if you desire, but all questions on this application must be answered. For questions and / or guidance, please contact our HR department at 210.736.4300.1. POSITION APPLYING FOR 2. LOWEST SALARY ACCEPTABLE Name* First Middle Last 4. OTHER NAMES: Have you ever used another name for work, school or other purposes? If so, identify name(s) and dates used and circumstances. 5. MAILING ADDRESS Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 6. HOME ADDRESS Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 7A. HOME PHONE7B. MOBILE PHONE8. E-MAIL ADDRESS* 9. LANGUAGES: Please state all languages (including English) that you speak, read and write proficiently:SpeakReadWrite 10. EDUCATIONSchoolName/Location of SchoolCourse of StudyNo. of Yrs Completed (Do Not Include Dates of Attendance)Did you Graduate?Degree or Diploma Awarded 11. LIST MANUALS, EQUIPMENT AND/0R SPECIAL TRAINING PERTINENT TO THE POSITION APPLIED FOR:12. LIST LICENSES (INCLUDE NUMBER) AND/OR CERTIFICATES YOU HAVE WITH ARE PERTINENT TO THE POSITION APPLIED FOR): WORK EXPERIENCEWORK EXPERIENCE (INCLUDING MILITARY SERVICE) Under A, please indicate whether it is your PRESENT OR LAST EMPLOYER IF CURRENTLY NOT EMPLOYED. Provide information on all employment for the past 10 years or your 5 most recent employers, whichever is greater. Duties should include the most difficult or most important responsibilities, and/or most significant accomplishments in the position held. Begin with your present job or most recent job if you are currently unemployed.13A. Most Recent Employer13A. Is this your current employer? Yes No 13A. Name of Employer 13A. Phone13A. Supervisor 13A. Start Date MM slash DD slash YYYY 13A. End Date MM slash DD slash YYYY 13A. Position 13A. Type of Business 13A. Total Weekly Hours13A. Salary 13A. Duties Performed13A. Reason for Leaving13B. Previous Employer13B. Name of Employer 13B. Phone13B. Supervisor 13B. Start Date MM slash DD slash YYYY 13B. End Date MM slash DD slash YYYY 13B. Position 13B. Type of Business 13B. Total Weekly Hours13B. Salary 13B. Duties Performed13B. Reason for Leaving13C. Previous Employer13C. Name of Employer 13C. Phone13C. Supervisor 13C. Start Date MM slash DD slash YYYY 13C. End Date MM slash DD slash YYYY 13C. Position 13C. Type of Business 13C. Total Weekly Hours13C. Salary 13C. Duties Performed13C. Reason for Leaving13D. Previous Employer13D. Name of Employer 13D. Phone13D. Supervisor 13D. Start Date MM slash DD slash YYYY 13D. End Date MM slash DD slash YYYY 13D. Position 13D. Type of Business 13D. Total Weekly Hours13D. Salary 13D. Duties Performed13D. Reason for Leaving13E. Previous Employer13E. Name of Employer 13E. Phone13E. Supervisor 13E. Start Date MM slash DD slash YYYY 13E. End Date MM slash DD slash YYYY 13E. Position 13E. Type of Business 13E. Total Weekly Hours13E. Salary 13E. Duties Performed13E. Reason for Leaving 14. MILITARY SERVICE14A. BRANCH OF SERVICE 14B. RANK AT DISCHARGE 14C. RESERVE STATUS 14D. POSITION HELD 14E. SPECIALITY 14F. PLEASE IDENTIFY SPECIAL TRAINING AND/OR SKILLS LEARNED UNDER “ACTIVE DUTY” OR RESERVE 15. REFERENCESList three persons who have knowledge of your WORK qualifications -- not relatives. Use current and / or former supervisors, professors, department chiefs / directors, or others who have had the opportunity to evaluate your performance. PLEASE PROVIDE E-MAIL ADDRESSES FOR THE REFERENCES YOU LIST BELOW.15A. Reference 115A. Name 15A. Title 15A. E-mail 15B. Reference 215B. Name 15B. Title 15B. E-mail 15C. Reference 315C. Name 15C. Title 15C. E-mail 16. CRIMINAL RECORDPlease disclose any criminal offense that may appear on your record. There is no time limit to the questions regarding your criminal history. Unless a time limit is stated in a question, you must include information on ALL convictions, pleas and alternative adjudications that have occurred during your lifetime. Records of offenses by minors (under age 18) are not automatically sealed and should also be disclosed, except where non-disclosure is required under state law. If you are uncertain of the exact date or how a criminal offense was classified, state the approximate date, your understanding of the criminal classification, and note that you are unsure of any more specific information.16A. Have you ever pled guilty to any criminal offense (misdemeanor or felony) other than parking tickets? Yes No 16B. Have you ever pled nolo contendere (no contest) to any criminal offense (misdemeanor or felony) other than parking tickets? Yes No 16C. Have you ever been convicted of any criminal offense (misdemeanor or felony) other than parking tickets? Yes No 16D. If you answered yes to any of these questions, provide complete information on all criminal offense(s), date(s), location(s) (city/county and state) and disposition:OffenseDateLocationDisposition 16E. Have you EVER served any of the following for any criminal offense? NOTE: This list is not a complete description of all possible alternative disposition programs. If the alternative disposition you received is not specifically listed below, you MUST disclose it by checking the last option and specifically describing the program. Failure to disclose any type of alternative disposition program will be considered falsification and will result in rejection for or termination from employment.Check all that apply pretrial diversion suspended sentence/prosecution shock/challenge incarceration community-based punishment pretrial release probation (any type) community control/supervision/service deferral/diversion of prosecution unconditional discharge restorative justice program deferred adjudication postponed judgment conditional discharge pretrial intervention supervised release any other type of alternative, deferred, suspended, postponed or conditional prosecution, adjudication, disposition, sentence, program or release 16E. Describe TypeDependable Health Services will not deny employment to any applicant solely because the person has been convicted of a crime. Dependable Health Services will consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position for which you have applied.17. MOTOR VEHICLE RECORDThe following section must be completed only if you are applying for a position which requires operation of a motor vehicle (whether owned by the facility or you)17A. Driver's License No. 17B. Type of License Personal Commercial (CDL) 17C. Issuing State 17D. Expiration Date MM slash DD slash YYYY 17E. Has your driver's license ever been denied, curtailed, suspended, or revoked? Yes No 17E. If yes, provide complete information on action(s) taken, date(s), location(s), and disposition/current status17F. Have you had any moving violations during the past 5-years? Do not disclose information about arrests or criminal convictions that have been sealed or expunged. Yes No 17G. Have you been convicted nolo contender (no contest) for any driving offenses during the past 10-years? Yes No 17H. Have you pled guilty or to any driving offenses during the past 5-years? Yes No If you answered yes to any of the above questions, provide the offenses(s), location (city/state), date(s) and disposition/current status17I. Do you have current automobile liability insurance? Yes No If yes, provide expiration date MM slash DD slash YYYY IMPORTANT INFORMATIONPLEASE REVIEW BEFORE SUBMITTING THIS APPLICATION Job Application: Applications will only be accepted for specific job positions and will be considered active for six months following their submission. If applicants wish to be further considered after this time period, or for a job position not listed on this application, they must submit a new application. Post-Offer/Pre-Hire Medical Examination: All applicants who accept a position with Dependable Health Service which requires a health clearance will be required to successfully complete a post-offer/pre-hire physical examination. Failure to satisfactorily meet or complete the specific requirements of the examination may result in your disqualification for or termination from employment. Drug Testing: All applicants extended a conditional job offer will be asked to submit to testing for the current illegal use of drugs. Any applicant who declines to consent or submit to testing, or who produces a positive test result for the illegal use of drugs, will not be further considered for employment. Background Investigation: When you sign this job application, you authorize Dependable Health Services, Inc. to seek and obtain information regarding your suitability for employment. All factors which are job related may be investigated (e.g., previous employment, educational credentials, and criminal record). All information obtained may be used to determine your eligibility for employment in accordance with equal employment opportunity guidelines. If Dependable Health Services requests a background check/criminal record under the Fair Credit Reporting Act, a separate notice will be provided regarding that investigation and written authorization will be required as a consideration for employment.18. APPLICANT VERIFICATIONI verify that all of the information on this application and on resumes and exhibits submitted to Dependable Health Services is true, correct, and complete. I have not omitted any information sought by Dependable Health Services. I understand that any false, misleading, incomplete or omitted information on this application or in resumes and exhibits submitted to Dependable Health Services will result in ineligibility for employment or termination of employment, whenever discovered. I understand that this application is not a job offer or employment contract with Dependable Health Services. The employment relationship between Dependable Health Services and applicants hired for employment is at-will. I further understand that at-will employment status will in no way limit my rights under Section 7 of the National Labor Relations Act to seek alteration of that relationship. Applicants hired by Dependable Health Services must complete a Federal I-9 form and provide verifying documentation of their legal right to reside and work in the United States. I hereby release previous employers/related sources from legal liability for information they provide regarding my suitability for employment. If employed, I shall comply with Dependable Health Services policies, rules and procedures.Check to confirm* Confirm Date* MM slash DD slash YYYY Upload Resume if DesiredMax. file size: 50 MB.