On-Line Employment Application

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Pursuant to Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination in Employment Act of 1975, the Vietnam Era Veterans Readjustment Act of 1984, Executive Order 11246, and the Americans With Disabilities Act of 1992, their implementing regulations, or any other federal, state or local law, order rule or regulation, First Call does not discriminate in the provision of services or in employment on the basis of age, race, color, marital status, religion, creed, sex, veteran or military status, national origin, physically or mentally disabled, or any other legally protected category.

Personal Information:
License Type: RN   LPN   Other   License Number:
License State: Social Security No:
 
*Name: Other names used:
*Address: *City:
State: Zip:
Home Phone: Work Phone:
Cell Phone: Pager:
*E-Mail:
 
What staffing or home care agencies have you
worked for in the past three years?
Have you ever been convicted of a crime other than a minor traffic offense? Yes   No
      If yes, describe:
 
Transportation:
Driver's License No: Driver's License State:
 
Please tell us what type of employment you are seeking:
Job or type of job:Full or part time: Full   Part   
Shift length: 8 hr.   12 hr.    Shift preference: D   E   N  
 
Education:
Vocational/Technical School
Name & Address: From - To Dates:
Graduated: Yes   No Degree Earned:
Hospital
Name & Address: From - To Dates:
Graduated: Yes   No Degree Earned:
College/University
Name & Address: From - To Dates:
Graduated: Yes   No Degree Earned:
Post Graduate
Name & Address: From - To Dates:
Graduated: Yes   No Degree Earned:
Additional Education/Training
Name & Address: From - To Dates:
Graduated: Yes   No Degree Earned:
 
Professional References:
Please list the requested information for licensed nurses, EXCLUDING friends, relatives or former employers.
Reference #1
Name: Classification:
Address: Telephone:
Reference #2
Name: Classification:
Address: Telephone:
Reference #3
Name: Classification:
Address: Telephone:
Reference #4
Name: Classification:
Address: Telephone:
Reference #5
Name: Classification:
Address: Telephone:
 
Work History:
Present Employer:
Name: Unit/Floor:
Address: City:
State: Zip:
Phone: From -To Dates:
Supervisor Name: Title:
Your position & duties: Shift Worked:
Reason for leaving: Hourly pay/Salary:
Previous Employer:
Name: Unit/Floor:
Address: City:
State: Zip:
Phone: From -To Dates:
Supervisor Name: Title:
Your position & duties: Shift Worked:
Reason for leaving: Hourly pay/Salary:
Previous Employer:
Name: Unit/Floor:
Address: City:
State: Zip:
Phone: From -To Dates:
Supervisor Name: Title:
Your position & duties: Shift Worked:
Reason for leaving: Hourly pay/Salary:


*Which of our offices would you like to receive this application?     Tulsa, OK
     Oklahoma City, OK
     Springfield, MO
     Dallas, TX


 Please tell us how you heard about First Call:  

Contract:
     First Call does not unlawfully discriminate in the provision of services or employment because of race, religion, color, sex, age, marital status, national or ethnic origin, physical or mental disability, or any other protected basis. I hereby authorize the schools, companies, former employers and all other persons named in this application to give any information regarding my employment, education, driving record, conviction records or character. I hereby release First Call and said schools, agencies, companies, former employers and all other persons named in this application from all liability for any damages resulting from issuing this information. I agree, during my employment with First Call, I am strictly prohibited from seeking or accepting employment, either directly or indirectly, in any capacity, from any home care, private duty or facility client assigned to me by First Call. I am also strictly prohibited from seeking or accepting employment, either directly or indirectly, in any capacity from any home care, private duty or facility client assigned to me by First Call after my assignment ends with any such client for any reason and for a period of ninety (90) calendar days thereafter. We also explain this Non-Solicitation/Finder's Fee Policy to all First Call clients and enforce this policy against clients and employees who violate it. Your violation of the policy may subject you to disciplinary action and/or legal action for which we will seek damages in an estimated amount of up to $10,000, as well as all other available remedies in law and equity. I understand and agree that nothing contained in this employment application or granting of an interview creates an employment contract between First Call and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no promise or guarantee is binding upon First Call unless made in writing prior to the date of this application. If an employment relationship is established, I understand that my employment will be terminable "at will," that I will have the right to terminate my employment at any time, and that First Call will retain a similar right to terminate my employment at any time. I agree not to transport a client in my vehicle or their vehicle without the express knowledge and permission of First Call. I certify that the foregoing answers to the questions asked in this application and on the accompanying Work Experience Record are true and correct to the best of my knowledge. I understand that falsification of information or misinformation hereon may result in discharge at any time it becomes known by First Call.


Acceptance:

I affirm that the information provided is true and correct to the best of my knowledge. I understand that failure to provide true and correct information may result in the rejection of my application. I agree to the terms and conditions described in the "Contract" above. I understand that entering my Name and the Date in the Acceptance area immediately below is in all respects equivalent to the affixation of my written signature.

Acceptance:

Name:   Date:


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Thank you.

   

Thank you for your interest in First Call.