Regent Care Center

Welcome to Regent Management Services

Employment Form

Please visit our Open Position page for a list of current positions .

We offer excellent benefits including company paid life insurance, a 401K program, medical, dental and vision plans. We also have employee recognition programs.

You can apply in person, by fax at 409-770-0233, or by using our on-line application service below. Please feel free to call 409-763-6000 if you need additional information.

Name:
Address:
City:	State/Province:
Zip/Postal:
Phone:
E-mail:

Facility:

	Desired Hours: shift Full-Time Part-Time Desired Job: Desired Salary: Date Available: Are you employed now: YES NO If so, may we inquire of your present employer? YES NO
Education:	Graduate School: Name and location of school Course of Study Years completed 1 2 3 4 Degree or Diploma College: Name and location of school Course of Study Years completed 1 2 3 4 Degree or Diploma Business/Trade/Technical: Name and location of school Course of Study Years completed 1 2 3 4 Degree or Diploma High School: Name and location of school Course of Study Years completed 1 2 3 4 Degree or Diploma
General:	Subject of Special Study or Research Work: Job related skills (computers, driver's license, etc.):
Employment:	Please give accurate, complete employment record. Start with your present or most recent employer: Company name 1 From - To: Salary: Reason for leaving: Telephone: Company address: Company City/State/Zip: Company Supervisor name: Job Title and description of your work: Company name 2 From - To: Salary: Reason for leaving: Telephone: Company address: Company City/State/Zip: Company Supervisor name: Job Title and description of your work: Company name 3 From - To: Salary: Reason for leaving: Telephone: Company address: Company City/State/Zip: Company Supervisor name: Job Title and description of your work: Company name 4 From - To: Salary: Reason for leaving: Telephone: Company address: Company City/State/Zip: Company Supervisor name: Job Title and description of your work: Professional References: Name 1: Business: Address: City/State/Zip: Telephone: Name 2: Business: Address: City/State/Zip: Telephone: Name 3: Business: Address: City/State/Zip: Telephone: I authorize investigation on all statements contained in this application. I understand that misrepresentation of information requested is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without cause and without previous notice. Date Print name
	How did you hear about us Newspaper - if so which one: Friend Employee Referral - if so which one: CareerBuilder.com HoustonJobs.com AustinJobs.com CityofHouston.com Other - if so which one:

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Telephone: 409-763-6000 - Fax: 409-770-0233

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