Parker County Hospital District

Human Resources

1130 Pecan Street

Weatherford, TX 76086

http://www.pchdtx.org

email: jobs@pchdtx.org

It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

This application can be active as long as legally required.

First Name

Last Name

Email Address

Check here to confirm that your email is correct.

Address Line 1

Address Line 2

City

State

Postal Code

Phone Number

Previous Address

Address Line 1

Address Line 2

City

State

Postal Code

Phone Number

Are you at least 18 years old?

Yes
No

Yes

Type of Position

Full Time
Part Time
PRN

Full Time

Part Time

PRN

Salary Requirement

If overtime work is required periodically, does this pose a problem for you?

No
Yes

Yes

Date Available For Work

Are You Legally Authorized to Work in the U.S.?

Yes
No

Yes

Have you ever worked in this facility?

No
Yes

Yes

If yes, what facility?

Are you related to another facility employee?

No
Yes

Yes

Application Addendum

1. Have you ever been convicted of a crime, had adjudication of a crime withheld, or pled nolo contendere to a crime?

If yes, please state the circumstances with regard to each.

Details, if applicable:

2. Have you been arrested for any crime that had not been adjudicated?

If yes, please state the circumstances and current status of each arrest.

Details, if applicable:

3. Have you ever committed a crime for which you were not arrested or convicted?

If yes, please state the circumstances.

Details, if applicable:

4. Have you ever been a defendant in a civil action for intentional tort? Intentional tort commonly refers to examples, such as assault, battery, and false imprisonment:

If yes, please state the circumstances.

Details, if applicable:

* Note: Answering "Yes" to any of these questions may not necessarily disqualify you from the position desired.

Each action and explanation will be weighted / considered in relationship to the position for which you are applying.

State Employment Commission
Agency
Job Listing
Current Employee
Indeed
Internet
Ad
School
Job Line
Other

If other, list here.

Are you presently charged with any violation of the law?

No
Yes

Yes

If yes, give date, place and nature of each such event:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you aware of any potential exclusion from a federally funded health program?

Please select:

No
Yes

Proficient in Software:

Business machines and/or equipment you can operate:

Other:

Current or Most Recent Work History

Organization

Address

Phone Number

Start Date

End Date

Name While Employed

Job Title

Job Type

PRN
Part-Time
Full-Time

PRN

Part-Time

Full-Time

Nature of Duties

# Hrs/Week

Salary

Reason For Leaving?

Immediate Supervisor

May We Contact?

Previous Work History

Organization

Address

Phone Number

Start Date

End Date

Name While Employed

Job Title

Job Type

PRN
Part-Time
Full-Time

PRN

Part-Time

Full-Time

Nature of Duties

# Hrs/Week

Salary

Reason for Leaving?

Immediate Supervisor

May We Contact?

Previous Work History

Organization

Address

Phone Number

Start Date

End Date

Name While Employed

Job Title

Job Type

PRN
Part-Time
Full-Time

PRN

Part-Time

Full-Time

Nature of Duties

# Hrs/Week

Salary

Reason for Leaving?

Immediate Supervisor

May We Contact?

Reference 1

Full Name

Position

Address

City/State

Phone Number

Reference 2

Full Name

Position

Address

Phone Number

Reference 3

Full Name

Position

Address

Phone Number

I certify that my answers are true and complete to the best of my knowledge.
*

Applicants Full Name

Date Prepared

Patient Care Tech - LVN - RHC Application

Previous Address

Application Addendum

Educational History

High School

College

College

Graduate School

Other

Licenses/Certifications/Skills

Current or Most Recent Work History

Previous Work History

Previous Work History

Reference 1

Reference 2

Reference 3

Licenses/
Certifications/Skills