Position Applied For
Previous Facility Types worked: Check All That Apply:
Employment desired
Language Skills: Other than English, please check any other languages you speak
Check the days of the week you are available to work:
Has your professional license ever been suspended, revoked or under investigation?
If currently employed, may we contact your employer?
Are you a veteran?
Provide the following employment information, beginning with the most recent employer.
May we contact for reference
May we contact for reference
May we contact for reference
List previous three (3) educational institutions attended, beginning with the most recent.

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Valid in State/Province?
Please list three professional references.


Are you legally authorized for employment in the USA?
Have you ever been convicted of a felony?
Can you pass a pre-employment drug test?
How were you referred to A LIFE SAVER ASSISTED LIVING LLC?
What is your means of transportation?
What type of shifts are you applying for?
Can you withstand periodic contact with cats or dogs?
I understand that I must report all accidents to my immediate supervisor and to A LIFE SAVER ASSISTED LIVING LLC - - No MATTER HOW SLIGHT.
Consent for Drug/Alcohol Testing and Criminal Background Checks
I hereby consent to taking drug and alcohol screening and testing if asked. I understand that A LIFE SAVER ASSISTED LIVING LLC has a zero (0) tolerance for drug use or substance abuse. I understand that when notified by the company I have two-hour window in which to have the drug and alcohol testing completed at the facility selected by the company. I understand that not agreeing to go in the designated time frame, being late for, or not showing up at all to the drug and alcohol screening within the designated time will reflect the same as “positive” test results, and I can be terminated. As well, I authorize the company to conduct criminal background checks, DMV checks and perform any checks on myself as may be necessary for initial and ongoing employment with the company. I authorize all tests and background check results be released to the company and understand that the results will become part of my permanent record.
ACKNOWLEDGMENT (Please read carefully and accept)
In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment. I give A LIFE SAVER ASSISTED LIVING LLC permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by A LIFE SAVER ASSISTED LIVING LLC with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, A LIFE SAVER ASSISTED LIVING LLC may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release A LIFE SAVER ASSISTED LIVING LLC, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. This agency will check the employee misconduct registry (EMR) maintained by DADS. As required by TAC 93.3 and Chapter 253, Texas Health and Safety Code. In consideration of my employment and of my being considered for employment by A LIFE SAVER ASSISTED LIVING LLC, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either A LIFE SAVER ASSISTED LIVING LLC, or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representativeA LIFE SAVER ASSISTED LIVING LLC, at any time, can constitute a contract of employment. No representative or agent of A LIFE SAVER ASSISTED LIVING LLC has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment, I agree that my continued employment may be contingent on the results. I understand that A LIFE SAVER ASSISTED LIVING LLC is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional’s practice. The Professional fully indemnifies A LIFE SAVER ASSISTED LIVING LLC against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law.