Hiring

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PERSONNEL FACE SHEET

Patient First Name

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Patient Last Name

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Date of Birth

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Address

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Address

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Telephone Number

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Emergency Contact Name

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Emergency Contact Phone Number

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Date of Hire

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Department

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Position

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Initial Pay Rate

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EMERGENCY CONTACT INFORMATION

EMPLOYEE NAME

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EMPLOYEE NUMBER

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SOCIAL SECURITY NUMBER

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POSITION

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DEPARTMENT

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MANAGER

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WORK PHONE

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HIRE OF DATE

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TODAY'S DATE

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EMPLOYEE'S HOME INFORMATION

HOME PHONE

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CELL PHONE

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OTHER PHONE

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STREET

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CITY, STATE AND ZIP

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RELATIONSHIP TO EMPLOYEE

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PHYSICIAN INFORMATION

NAME

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PHONE NUMBER

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STREET

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CITY, STATE AND ZIP

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[ ] GP

[ ] OB/GYN

[ ] Dentist

[ ] Eye Doctor

[ ] Allergist

APPLICATION FOR EMPLOYMENT

APPLICANT

NAME

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HOME PHONE

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WORK PHONE

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CELL PHONE

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PRESENT STREET ADDRESS

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CITY, STATE AND ZIP

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ARE YOU 18 YEARS OF AGE OR OLDER?

Yes

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ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED IN THIS Yes COUNTRY DUE TO A VISA OR IMMIGRATION STATUS?

Yes

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WILLING TO ACCEPT:

PRN

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WILLING TO WORK:

Day

Swing

Night

Rotating

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POSITION APPLYING FOR

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SALARY DESIRED

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HIRING MANAGER

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WORK EXPERIENCE (starting with the most recent)

COMPANY NAME, LOCATION and PHONE NUMBER

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POSITION/TITLE

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FROM/TO DATES

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SALARY

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REASON FOR LEAVING

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MAY WE CONTACT YOUR CURRENT EMPLOYER?

Yes

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OCCUPATIONAL LICENSE, CERTIFICATE OR REGISTRATION

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NUMBER

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ISSUING AUTHORITY

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EXPIRATION DATE

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Outcomes Detox Center

SPECIAL/TECHNICAL SKILLS

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INTEREST IN POSITION

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HAVE YOU BEEN CONVICTED OF A FELONY?

Yes

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OTHER

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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 INVESTIGATIONS OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE 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, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.

SIGNATURE

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Date

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CONSENT TO OBTAIN D.P.S. CRIMINAL BACKGROUND CHECK

Applicant:

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DATE APPLICATION

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By checking this box, I hereby give my consent to allow Outcomes Detox Center, LLC to conduct a criminal background check using TEXAS DEPARTMENT OF PUBLIC SAFETY records. I understand that this documentation will be used to evaluate my future employment with Outcomes Detox Center, LLC. If hired, I understand that this information will be placed in my personnel record, accessible only by the management of Outcomes Detox Center, LLC

I consent

CONSENT FOR PRE-EMPLOYMENT DRUG-SCREEN

By checking this box, I hereby give my consent to allow Outcomes Detox Center to conduct a pre-employment drug test. I understand that documentation regarding this test will be used to evaluate my future employment with Outcomes Detox Center. If hired, I understand that this information will be placed in my personnel record, accessible only by the management of Outcomes Detox Center.

I consent

HEPATITIS B VACCINE DECLINATION STATEMENT

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to me; however, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Employee Printed Name

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Representative of Outcomes Detox Center

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

DATE

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