Welcome, and thank you for your interest in working for Big Country Healthcare Services! We are a locally owned & operated home health agency in the Abilene, TX area. We have been providing extraordinary skilled nursing & therapy services to Abilene and the rest of the big Country since 2006. Please answer all questions that are asked on the application, if the question does not apply then please type "n/a" in the blank and continue on. If you have any questions call our office number at (325) 675-0559.
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Name

(Last Name, First Name)
 
Who referred you to our agency?

(Who referred you to apply for this position?)
 
Social Security #

 
Are you at least 18 years of age?

     
 
Present Address

(STREET, CITY, STATE, ZIP)
 
Permanent Address

(STREET, CITY, STATE, ZIP)
 
Phone Number

(Area Code)
 
What position are you applying for?


 
What is the soonest you can start work?

 
What is your desired salary?

 
What type of employment are you seeking?


 
High School

(Name, Location, Years Attended, Subjects Studied)
 
Did you graduate from high school?


 
If so, when did you graduate from high school?

 
College

(Name, Location, Years Attended, Subjects Studied)
 
Did you graduate from college, if so what achievement did you earn?


 
Please specify the college degree in which you recieved.

(Major, Minor, Program of Certification, Etc.)
 
Did you graduate from trade, business, or correspondence school?


 
Please Specify what trade, business, or correspondence school program you graduate from.

 
Please describe any subjects of special study, research work, or special training skills that you have acquired.

 
US Military or Naval Service

Branch & Rank
 
Who is your current/ latest employer?

(Provide company name & address of employer)
 
Start Date

 
End Date

 
What was your position?

 
What was your reason for leaving?

 
What was your salary?

 
Previous Employer

(Provide company name & address of employer)
 
Start Date

 
End Date

 
What was your position?

 
What was your reason for leaving?

 
What was your salary?

 
Previous Employer

(Provide company name & address of employer)
 
Start Date

 
End Date

 
What was your position?

 
What was your reason for leaving?

 
What was your salary?

 
Previous Employer

(Provide company name & address of employer)
 
Start Date

 
End Date

 
What was your position?

 
What was your reason for leaving?

 
What was your salary?

 
Personal Reference

Provide the name of a person not related to you, whom you have known for at least one year.
 
Address/ Phone Number

 
Business/ Occupation

 
How many years have you known this person?


 
Personal Reference

Provide the name of a person not related to you, whom you have known for at least one year.
 
Address/ Phone Number

 
Business/ Occupation

 
How many years have you known this person?


 
Personal Reference

Provide the name of a person not related to you, whom you have known for at least one year.
 
Address/ Phone Number

 
Business/ Occupation

 
How many years have you known this person?


 
1. Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.


 
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

   I AUTHORIZE AN INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED TO GIVE YOU ANY AND ALL PERTINENT INFORMATION THAT MAY HAVE, PERSONAL, OR OTHERWISE, AND RELEASE THE COMPANY FROM LIABILITY FOR ANY DAMAGES THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION. I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY A COMPANY REPRESENTATIVE.
   
   I ALSO UNDERSTAND THAT A CRIMINAL HISTORY BACKGROUND CHECK MAY BE DONE ON ME BEFORE I AM CONSIDERED FOR EMPLOYMENT WITH BIG COUNTRY HEALTHCARE SERVICES.

(Electronic Signature)
 
Electronic Signature Date

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