Post Acute Medical, LLC is an equal opportunity employer. Qualified applicants will be considered for vacancies without regard to race, color, religion, sex, national origin, age or disability (physical or mental). Information requested on this application will not be used to discriminate against any applicant for employment.

PERSONAL INFORMATION:

Last Name:   First Name: MI:
Address: 
City:   State:   ZIP:
Phone (XXX-XXX-XXXX):
In Case of Emergency Notify:  Name:    Phone:
Full Address:  

Position(s) Desired: 1:   2: 3: 
Available: Full Time Part Time Temporary Other Shift Desired: Any Days Evenings Nights
Location Desired: Corporate Office Warm Springs Rehabilitation Hospital of San Antonio Warm Springs Specialty Hospital of Luling Warm Springs Specialty Hospital of Victoria The Springs Residential Brain Injury Program Warm Springs Rehabilitation Center - Northeast Warm Springs Rehabilitation Center - Northwest Warm Springs Rehabilitation Center - Lockhart Pearsall/Frio Rehabilitation Center Connally Memorial Rehabilitation Center Central Texas Medical Center
Desired Salary: Date Available to Work (mm/dd/yy):
Skills: Typing Speed: Dictation: Other:

Have you used any other name for school, work or other reasons?
No Yes
If yes, please provide name and dates/locations used:

Have you ever pled guilty to, been convicted of, or received deferred adjudication, pretrial diversion or
probation for any crime (misdemeanors and felonies), other than minor traffic violations?
No Yes
If yes, please provide a list of all criminal offenses, dates, courts and disposition.

Are you currently serving deferred adjudication, pretrial diversion or probation for any crime?
No Yes
If yes, please provide date, current status and expected disposition.

Post Acute Medical, LLC will conduct criminal history checks of final applicants for employment.
Conviction of a crime is not an automatic bar to consideration for employment. However, applicants
for home health positions will be barred from employment under applicable Texas laws.

Have you ever been or are you presently, named in any administrative, governmental, professional
or legal action alleging professional negligence or malpractice?
No Yes
If yes, please provide details, including the dates and amounts of any settlements or judgments
made by you or in your behalf:

EDUCATION:

Highest Grade Completed: Grade 1 Grade 2 Garde 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 High School 9 High School 10 High School 11 High School 12 College 1 College 2 College 3 College 4 Other 1 Other 2 Other 3

Have you ever applied for or worked at any Warm Springs/Post Acute Medical, LLC Facility? No Yes
If yes, name of facility:
Are you related (by blood, marriage or otherwise) to any employee at this facility? No Yes

EMPLOYMENT EXPERIENCE:

Please supply your complete employment history (full-time, part-time and contract) for the past
7 years or 5 prior employers, whichever is greater. Begin with your most recent employment.
Explain all periods of unemployment.

EMPLOYER 1:

Employer:  
Address:    
Supervisor's Name: Position Held:
Dates Employed (mm/yy): to
Description of Duties:

Reason for Leaving:

EMPLOYER 2:

Employer:  
Address:    
Supervisor's Name: Position Held:
Dates Employed (mm/yy): to
Description of Duties:

Reason for Leaving:

EMPLOYER 3:

Employer:  
Address:    
Supervisor's Name: Position Held:
Dates Employed (mm/yy): to
Description of Duties:

Reason for Leaving:

EMPLOYER 4:

Employer:  
Address:    
Supervisor's Name: Position Held:
Dates Employed (mm/yy): to
Description of Duties:

Reason for Leaving:

EMPLOYER 5:

Employer:  
Address:    
Supervisor's Name: Position Held:
Dates Employed (mm/yy): to
Description of Duties:

Reason for Leaving:

Have you ever been discharged or asked to resign by any other employer not listed above?
No Yes
If yes, please provide a full explanation, including employer, dates, actions taken and explanation.

MILITARY:

Branch: Years Served: Classification:
Duties and Responsibilities:

Type of Discharge:

Are you capable of performing the duties of the position(s) for which you have applied (a job
description for the position is available upon request)?
Yes No

How were you referred to Post Acute Medical/Warm Springs? Advertisement Employee School Other

Professional or trade license or registration:
State: Number: Expiration Date (mm/dd/yy):
Are there any restriction/stipulations on your license?
No Yes
Have you ever been denied a professional or trade license or registration?
No Yes
Has your professional or trade license ever been revoked, suspended or subject to discipline by
any board or governing authority?
No Yes
If you answered yes to any of these questions, please explain fully.

REFERENCES:

Please include name, title, current address and phone number of four professional or character
references. (Do not include any past employers or relatives)

Name: Title:
Phone Number (XXX-XXX-XXXX): 
Current Address: 

Name: Title:
Phone Number (XXX-XXX-XXXX): 
Current Address: 

Name: Title:
Phone Number (XXX-XXX-XXXX): 
Current Address: 

Name: Title:
Phone Number (XXX-XXX-XXXX): 
Current Address: