Application Form

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Company

This field is for validation purposes and should be left unchanged.

Important Notice
Please complete all required fields. If a question does not apply to you, enter “N/A.” For required numeric fields, enter “0000.”
Required information is collected to meet state regulatory requirements. Failure to provide required information may affect eligibility for employment. For technical issues, please contact us at HR@dghcares.com.

Personal Information

First Name(Required)

Middle Name(s)

Last Name(Required)

Address 1(Required)

City(Required)

State(Required)

Zip Code(Required)

Email(Required)

Cell Phone(Required)

Secondary Number

Open to Live-In Care(Required)

Yes

Have you ever been convicted of a felony that has not been sealed, expunged, or pardoned?(Required)

Yes

A conviction does not automatically disqualify an applicant.

Vehicle Information

Transportation information is collected to assess job-related requirements.

Valid Texas Driver’s License?(Required)

Yes

Reliable Transportation Available?(Required)

Yes

Vehicle Year(Required)

Vehicle Make/Model(Required)

Health and Safety Requirements

Have you had a TB test in the last 3 Years?(Required)

Yes

Documentation will be required prior to client assignment.

Result

Positive

Negative

Work Preference

Ideal Hours per Week(Required)

Hourly Pay Expectation

Shift Availability

Monday

Morning

Mid-Day

Evening

Night

Tuesday

Morning

Mid-Day

Evening

Night

Wednesday

Morning

Mid-Day

Evening

Night

Thursday

Morning

Mid-Day

Evening

Night

Friday

Morning

Mid-Day

Evening

Night

Saturday

Morning

Mid-Day

Evening

Night

Sunday

Morning

Mid-Day

Evening

Night

Education

Highest Level of Education(Required)

Less than High School

Some High School (No Diploma)

High School Diploma or GED

Some College (No Degree)

Associates Degree

Bachelors Degree and Higher

List Trade/Technical and/or Vocational Certificates

Training and Certifications (Select all that apply)(Required)

Personal Care Aide Training

CNA

CPR / First Aid

Dementia / Alzheimer’s Training

Other

Other Experience That Supports This Role:

Include experience related to personal care, mobility assistance, dementia support, hospice care, or use of medical equipment.

Reference

First Reference

Name(Required)

Relationship(Required)

Phone(Required)

Years Known(Required)

Second Reference

Name(Required)

Relationship(Required)

Phone(Required)

Years Known(Required)

Employment History

Present/Last Employer

Employer Name(Required)

Telephone(Required)

Supervisor's Name(Required)

From Date(Required)

Month

Day

Year

To Date

Month

Day

Year

If you are currently employed, leave this field blank.

Position Title(Required)

Summary of Duties

Include duties related to personal care, companionship, household assistance, or similar support services.

Previous Employers

Employer Name(Required)

Telephone(Required)

Supervisor's Name(Required)

From Date(Required)

Month

Day

Year

To Date(Required)

Month

Day

Year

Position Title(Required)

Summary of Duties

Include duties related to personal care, companionship, household assistance, or similar support services.

Optional Résumé / CV Upload

Max. file size: 64 MB.

Certification, Authorization & Electronic Signature(Required)

By signing, I certify this information is true and authorize required background, registry, and reference checks. Employment is contingent upon compliance with HHSC requirements, including clearance of the Texas Nurse Aide Registry and OIG exclusion list.

Full Legal Name(Required)

By typing my name above, I understand and agree that this constitutes my electronic signature and has the same legal effect as a handwritten signature.

Date(Required)

Month

Day

Year

Client Login

Personal Information

Vehicle Information

Health and Safety Requirements

Work Preference

Shift Availability

Education

Reference

First Reference

Second Reference

Employment History

Present/Last Employer

Previous Employers