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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.

You can select multiple items from the lists that say "Multi Select" by holding down the Control (Windows) or Command (Mac) key while clicking on the items in the list.

Personal Information

Best contact method:
License type:
Attach your resume:
(doc, docx, or pdf format)


You can select multiple items from the lists that say "Multi Select" by holding down the Control (Windows) or Command (Mac) key while clicking on the items in the list.

Have you ever been convicted of a crime other than a minor traffic offense?


List all cities, counties and states you have lived in for the last SEVEN years:

Work Preference

You can select multiple items from the lists that say "Multi Select" by holding down the Control (Windows) or Command (Mac) key while clicking on the items in the list.

Education:

1. Vocational/Technical School/College/University/Hospital-based

2. Vocational/Technical School/College/University/Hospital-based

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All fields marked * are required and must be completed.

Work History

Present Employer

Previous Employer

Previous Employer

Professional References

Please list the professional references who are LICENSED NURSES or THERAPISTS, EXCLUDING friends, relatives or former employers.

Reference #1

Reference #2

Reference #3

Reference #4

Agency Work History

First call is interested in giving you credit for all of your work history. If you have work history with another agency, it will be helpful in giving you credit for all of your experience. Providing this information will allow us to offer you assignments as quickly as possible.

Agency #1

Agency #2

Agency #3

Agency #4

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.

Additional Forms

All applicants will be required to review the additional form located here.
Texas applicants will additionally be required to review the forms located here and here.

Please review the additional form(s) now. You do not need to complete the forms at this time, but by submitting this application you affirm that you have reviewed the forms and agree to their terms, and authorize First Call to collect the information described in them, as applicable.

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" and "Additional Forms" paragraphs 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.

Before you submit this form, please review it for accuracy and completeness. We cannot process your application without complete information.

Please note that this form contains quite a bit of information and may take a few minutes to process. Please click the submit button only once and wait for the upload process to complete.
Thank you.