Placement Application

(Employment, Volunteers, Students, Contractors)

Thank you for your interest in Metrocare Services, north Texas' leading nonprofit dedicated to helping people with mental illness, developmental disabilities, and severe emotional problems live healthier lives.
Please see directions on page 4 on how to submit your application to Human Resources.

PERSONAL DATA
To express an interest in a position with our Center please complete this application. Applications are required on all persons who are hired by the Center. Failure to provide sufficient, truthful (and verifiable) information is grounds for the application to be rejected and not considered for an employment opportunity. If employment has commenced it is ground for disciplinary action up to and including termination of employment.

Last Name Miranda Email: Address: Zip Code:

First Name Rhonda

Middle Name: Jeanine "Nick" Name: N/A Unit #:

rhonda.miranda@dshs.state.tx.us 407 Cates Drive 7 5 1 4 2

Tele 1: 972-750-1278

Tele 2: 469-600-9351

List all other names used (include school, employment): Rhonda Parcel, Rhonda Miranda, Rhonda Contreras How did you hear about this position: Metrocare Website School / University Employee / Prof Org /Other: I have lived outside the state of Texas within the last twenty-four (24) months. I have lived, worked, and/or attended school outside the state of Texas since the age of majority (18). List other states, countries you have lived: I have been convicted of a Felony or Class A misdemeanor and/or currently on deferred adjudication for a felony or Class A. List Felony, Class A misdemeanors and/or current deferred adjudications and details below: Monster Prof Assoc Y! / Hot Jobs Friend Morning News Star Telegram

A conviction of a Felony, Class A misdemeanor, or deferred adjudication will not necessarily disqualify you from employment with our Center. Each situation must be evaluated separately - and completely. Failure to disclose may result in disqualification from employment.

EMPLOYMENT DESIRED
1st Choice Part-time Sal Req: 2nd Choice PRN Day Shift Full Time Volunteer 072110 Evenings Part Time 3rd Choice Fulltime Late Shift As Needed Weekends Temporary

Student / Fellow / Practicum / Intern / Extern Page 1 of 4

072110

Last Name Miranda

First Name Rhonda

Page 2 of 4

CREDENTIALS Check all that apply

Transcripts (records) must be submitted to verify credentials. Diploma/GED AA/AS BA/BS/BSW MA/MS/MSW Spanish LCDC LPC-i LPC / LPC-S PhD, PsyD American Sign LBSW LMSW LCSW LMFT NP / APN PHYS ASST MD / DO Rx AUTHOR Vietnamese Specialty 2: Major : all classes Major : Nursing Major : Nusrsing (Bachelors) Check if you graduated Check if you graduated Check if you graduated CERTIFICATIONS (Boards, Advanced, Speciality...) Specialty 1:

Name of School Attended: Kemp High School Name of School 2 Attended: Trinity Valley Community College Name of School 3 Attended: UT Arlington

WORK EXPERIENCE - last 5 years; most recent first (Relevant volunteer activity can be listed below as well):
Organization Name Terrell State Hospital Position Title Job Duties Start Date June 2004 Start Pay End Date End Pay

still there 5500

RN

3816

chart, assess, teach, family education, treatment team, medications, new admissions, medical skills, supervise

Reason for leaving: still there Supervisor Name

Gloria Burns RN

Telephone 972-563-8934 Start Date Oct. 2008 Start Pay

Check if we can contact End Date End Pay

Organization Name Texas Health Resources Dallas Position Title Job Duties

Oct. 2010 34.89

RN

32.06

chart, assess, new admissions, family education, teaching

Reason for leaving: tired Supervisor Name

Salomie Devassy

Telephone 214-345-6789 Start Date Oct. 2007 Start Pay

25.00

Check if we can contact End Date End Pay

Oct. 2008 25.00

Organization Name Timberlawn Hospital Position Title Job Duties

RN chart, assess, triage, new admissions, medications

Reason for leaving: left to Texas Health, more money Supervisor Name
Paula Hiersberger RN

Telephone

Check if we can contact

List other employment:

072110

Page 3 of 4

Metrocare Services is required by law to run routine background checks on all final applicants for employment, contracts, internships and volunteer positions. By signing below, I certify that the information given by me in this application for placement with Metrocare Services is true, correct, and complete. If selected for employment, contract or placement, I acknowledge the following: Client Abuse/Neglect Affidavit: I certify that I have not received a confirmation by the Department of Family & Protective Services nor any other investigator with respect to any allegation of abuse, neglect, or exploitation naming me as a perpetrator. Should I be notified of an allegation or finding, I will notify Metrocare Human Resources and Quality Management departments within 24 business hours. Employment-At-Will & Placement At-Will: I understand that I am free to resign at any time, with or without cause and without prior notice, and Metrocare reserves the same right to terminate my employment or placement at any time, with or without cause and without prior notice, except as required by law. Any signed contractual agreement will supersede the at-will clause contained herein. Motor Vehicle Report: I understand that for positions, which require driving, I must be at least 18 years of age, have a valid Texas Driver's License and a good driving record. I further understand that my record will be checked for insurance purposes and if I am not insurable, I may be denied employment, placement and/or terminated if already employed. Pre-employment Controlled Substances Screening: I understand that I may be required to submit to a pre-employment/placement drug test that screens for illegal drugs and controlled substances; remain free of illegal drugs, alcohol and abusive levels of prescription drugs at work; and agree to the terms and conditions of random and for-cause testing for these substances. I understand failure to comply may result in immediate termination of the relationship with Metrocare Services. Fair Credit Reporting Act: As required by the Fair Credit Reporting Act, an investigative consumer report may be requested solely for employment purposes. If I am denied employment or placement, either wholly or partly, because of the information contained in a consumer report, a disclosure will be made to me of the name and address of the Consumer Reporting agency making such a report. Background Investigations: I hereby authorize Metrocare Services to investigate my past and current employment, education, criminal history, including but not limited to clearinghouse databases to include TDHS Employee Misconduct Registry, the TDHS Nurse Aide Registry, and the Department of Public Safety. If I am denied employment or placement, either wholly or partly, because of the information contained in a background report, a disclosure will be made to me of the information that affected the adverse placement or employment decision. Staff, volunteers and contractors must report convictions and pending criminal charges that are listed as bars to employment in the Texas Administrative Code to Human Resources in writing within 30 calendar days of arrest or within 10 calendar days of a court-ordered summons to appear, whichever is earliest.

I hereby authorize former employers and other persons with knowledge of my background, education or experience to release any and all information to Metrocare Services or its designee. I understand any information collected during such investigation will be confidential and I will not be given access to the information except in deference to the law and when written request is ma. I certify that the statements in this application are true and complete. I understand any false statement may be sufficient ground for my application to be rejected or for discharge if I am employed by Metrocare Services. This form must be submitted on all individuals named as a party to a contract with Metrocare or the proprietor (or official) of any business providing service on behalf of Metrocare Services. I attest the information provided herein is true and accurate: Yes, the information is true to the best of my knowledge. Type your full legal name is the space to the right: Date of Birth:
04/23/1965 2 6 4 6 Rhonda Miranda

Last 3 digits of Social Security #: Driver's Lic State: Texas

Last 4 of Driver's Lic #:

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INSTRUCTION FOR COMPLETING THIS APPLICATION

1.) Complete all relevant spaces on the form. 2.) You must save this form as described below. Any unsaved data will not be sent: Select "FILE," then "SAVE AS," title the file your last name and first name (example: "Smith Susan"). Send the file to CAREERS@MetrocareServices.org (make sure to attach the completed application). 3.) You may attach a resume to your emailed application; however all persons placed at Metrocare must submit an application. 4.) Applications are routed to hiring (placement) managers weekly. Hiring managers contact qualified candidates to schedule interviews. 5.) We cannot provide status updates on applications due to the high volume of resumes and applications received. 6.) Electronic (emailed) applications remain in our files for at least 2 years. 7.) Metrocare reserves the right to test applicants for use/abuse of controlled substances. 8.) Metrocare conducts thorough criminal background checks on all persons placed in our Center. 9.) Education credentials (transcripts, diplomas) will be reviewed as part of the finalist candidate review. 10.) Professional, educational and familiar (personal) references are completed as part of the finalist candidate review. All offers of placement (employment, assignment) are conditional until acceptable reference checks are completed.

REFERENCES (Must list at least 2 professional and or educational references. A third reference can be personal.)
Ref 1 Name: Zanette Cotton Former Employer Ref 2 Name: Janet Sims Former Employer Ref 3 Name: Alan Ransom Former Employer Tele #: 972-563-5363 Educational Reference Tele #: 972-834-8325 Educational Reference Tele #: 972-551-8294 Educational Reference Email: Personal Reference Email: Personal Reference Email: Personal Reference

NOTICE

The U.S. Equal Employment Opportunity Commission enforces federal laws prohibiting employment discrimination. These laws protect you against employment discrimination when it involves: Unfair treatment because of your race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information. Harassment by managers, coworkers, or others in your workplace, because of your race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information. Denial of a reasonable workplace accommodation that you need because of your religious beliefs or disability. Retaliation because you complained about job discrimination, or assisted with a job discrimination investigation or lawsuit.

VOLUNTARY DISCLOSURE OF INFORMATION

The answers to these questions are not considered part of the employment consideration process. We collect this information as part of our workforce diversity efforts in our organization. This data is also used to complete federally mandated forms. Your response to these three (3) questions is voluntary. Ethnicity
Anglo Caucasion (White)

Sex Current Date

Female
10/20/12

Position(s) Applied for: Registered Nurse