(If you became an employee of Americare In Home Care, you will be required to provide documentation proving your eligibility to work in the USA)

( NOTE: Application will not be considered complete without the applicant's signature)
I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I agree that, if hired, I may be discharged if Americare In Home Care learns of any falsification or material omission in the information I have provided and if discovered prior to hire, I would be ineligible for consideration not only for this position, but future positions, as well. (NOTE: You will not automatically be excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the totality of circumstances such as the nature of the crime, the recency of the conviction, the type of work involved, etc.)
I understand and agree that all information concerning patients and their families is strictly confidential. I am not permitted to disclose any financial, medical or personal information related to any patient or family member to fellow employees, company administrative staff or individuals, except my supervisor at Americare In Home Care.
I authorize Americare In Home Care to investigate my employment history, credentials, license verification and to obtain any relevant information, including a criminal background check needed to make an employment decision. I authorize Americare In Home Care to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize Americare In Home Care to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release Americare In Home Care and any individual or entity providing information to Americare In Home Care from all liability for any damage from the disclosure of this information.
I also understand and agree that passing a medical examination (which is my responsibility) and/or medical screening may be required. If medical restrictions cannot be reasonably accommodated, I may not be hire of if hired, I may be terminated.
I understand and agree that I may be subject to pre-employment drug testing and/or alcohol testing, random testing, as well as testing where reasonable suspicion or improper usage has occurred, or where warranted by an on-the-job injury, circumstance, workplace conditions or contractual requirements.
I understand and agree nothing contained in this employment application or in granting of an interview creates an employment contract between Americare In Home Care and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable "at will;" that is, I will have the right to terminate my employment at any time and that Americare In Home Care retains the same right to terminate my employment at any time.
I understand that should I become employed by Americare In Home Care, my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of Americare In Home Care.
I understand that Americare In Home Care is committed to promoting safety and high standards of employee performance, productivity and reliability. In order to achieve this, I may be subjected to a drug test prior being hired to assure Americare In Home Care I do not currently have narcotics, sedatives, stimulants or other controlled substances and/or mood-altering substances in my body. I understand if I have: any such substance: in my body at the time of the drug test, Americare In Home Care will not hire me.
I understand that Americare In Home Care reserves the right to add to, change and/or delete their policies, procedures, work rules and benefits at any time and that no one in Americare In Home Care has the authority to enter into any agreement for any particular period of time, or contrary to the above terms, unless that agreement is set forth in writing and signed by an authorized representative of Americare In Home Care.

Pursuant to Title VII of the Civil Rights Act of 1965 (42 U.S.C., §20000d et seq.) and 4.5 C.F.F. Part 80, §504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §6101 et seq.), Americare In Home Care adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment and for all persons employed by Americare In Home Care. Americare In Home Care offers equal employment and advancement opportunities to qualified individuals without regard to race, color, religion, sex, age, national origin, marital status, disability or any other category protected by any applicable local, state, federal law, ordinance or regulation.

I HEREBY AGREE THAT I WILL NOT SOLICIT, EITHER DIRECTLY OR INDIRECTLY, ON BEHALF OF MYSELF OR ANY OTHER PERSON, FIRM OR CORPORATION, EMPLOYMENT FIRM OR CORPORATION, EMPLOYMENT FROM A CLIENT OF THIS COMPANY WHICH I HAVE BEEN SENT OR REFERRED TO FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT FOR A PERIOD OF 90 DAYS FROM THE LAST TIME I WAS EMPLOYED OR
REFERRED TO FOR EMPLOYMENT TO SAID CLIENT, THE IDENTITY OF ANY CLIENT OR PROSPECTIVE CLIENT OF OR ACQUIRED THROUGH THE COMPANY SHALL BE DEEMED CONFIDENTIAL INFORMATION. IT IS SPECIFICALLY UNDERSTOOD THAT ANY VIOLATION OF THE ABOVE SHALL SUBJECT ME TO THE SUM
OF $750.00 AS DAMAGES. I AGREE TO A SEARCH OF THE NURSE AIDE REGISTRY AND THE EMPLOYEE MISCONDUCT REGISTRY AND I UNDERSTAND THAT IF I AM LISTED ON THESE REGISTRIES, I MAY NOT BE
EMPLOYED BY AMERICARE. I FURTHER AGREE TO A CRIMINAL HISTORY CHECK AND HAVE NO CONVICTION FOR AN OFFENSE DESCRIBED IN THE HEALTH AND SAFETY CODE 250-005.
Equal Opportunity Employer

STATEMENT OF EMPLOYABILITY
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. I understand that these checks will determine if l have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General's List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act.
Criminal History Check
I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact or have access to patient records until results are returned. I will be notified of results.
CONVICTIONS BARRING EMPLOYMENT.
(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:
♦ An offense under Chapter 19, Penal Code (criminal homicide);
♦ An offense under Chapter 20, Penal Code (kidnaping and unlawful restraint);
♦ An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
♦ An offense under Section 21.08, Penal Code (indecent exposure);
♦ An offense under Section 21.11, Penal Code (indecency with a child);
♦ An offense under Section 21.12, Penal Code (improper relationship between educator and student);
♦ An offense under Section 21.15, Penal Code (improper photography or visual recording);
♦ An offense under Section 22.011, Penal Code (sexual assault);
♦ An offense under Section 22.02, Penal Code (aggravated assault);
♦ An offense under Section 22.021, Penal Code (aggravated sexual assault);
♦ An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);
♦ An offense under Section 22.041, Penal Code (abandoning or endangering a child);
♦ An offense under Section 22.05, Penal Code (deadly conduct);
♦ An offense under Section 22.07, Penal Code (terroristic threat);
♦ An offense under Section 22.08, Penal Code (aiding suicide);
♦ An offense under Section 25.031, Penal Code (agreement to abduct from custody);
♦ An offense under Section 25.08, Penal Code (sale or purchase of a child);
♦ An offense under Section 28.02, Penal Code (arson);
♦ An offense under Section 29.02, Penal Code (robbery);
♦ An offense under Section 29.03, Penal Code (aggravated robbery);
♦ An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);
♦ An offense under Section 33.021, Penal Code (online solicitation of a minor);
♦ An offense under Section 34.02, Penal Code (money laundering);
♦ An offense under Section 35A.02, Penal Code (Medicaid fraud);
♦ An offense under Section 36.06, Penal Code (obstruction or retaliation);
♦ An offense under Section 42.09, Penal Code (cruelty to livestock animals);
♦ An offense under Section 42.092, Penal Code (cruelty to non-livestock animals); or
♦ A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
(B) An offense the Agency determines to be contraindicated to employment with the consumers the A person may also be barred from employment the duties of which involve direct contact with a client in a facility if convicted of any of the
following crimes within the past 5 years:
♦ An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony);
♦ An offense under Section 30.02, Penal Code (burglary);
♦ An offense under Chapter 31, Penal Code (theft that is punishable as a felony);
♦ An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or
♦ An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony) .
♦ An offense under Section 37.12, Penal Code (false identification as a peace officer); or
♦ An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).
(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:
♦ Of an offense under Section 30.02, Penal Code (burglary); or
♦ Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.
(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.