Employment Application Office to receive your Application: Personal Information License/Certification State: Main Field of Experience: Have you ever been convicted of a crime other than a minor traffic offense? (If yes, please describe): Please list all other cities, counties and states in which you have lived within the past 7 years: Employment History Professional References Please list the professional references who are LICENSED NURSES or Supervisors, EXCLUDING friends or relatives. Agency Work History Facilities at which you have worked through this agency: Facilities at which you have worked through this agency: 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. 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" paragraph 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. Print First and Last Name: Apply Your application has been submitted! Thank you!