On-Call HealthCare - Application for Employment OnCall Healthcare, Inc. is an Equal Opportunity Employer and does not unlawfully discriminate on the basis of race, sex, age, color, religion, national origin, sexual orientation, marital status, veteran status, disability status, or any other basis prohibited by federal, state, or local law. PERSONAL INFORMATION Select Title Miss Mr. Mrs. Ms. First Name Middle Initial Last Name Present Street Address Apt # City State Zip Code Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Telephone Number E-Mail Address Social Security Number (ONLY last 4 digits) Are you at least 18 years old? Yes     No Previous Address (if at present address less than 12 months) Apt # City State Zip Code Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Position Desired: Experienced? Type of Position: Preferred Shift: First Choice: Yes  No 8 Hours   Day Weekend Second Choice: Yes  No 10 Hours PRN Evening Rotation Third Choice: Yes  No 12 Hours   Night Salary Requirement: $ Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes     No Date Available for Work: If overtime work is required periodically, does this pose a problem for you? Yes     No Are you legally authorized to work in the U.S.? Yes     No Have you ever worked in a facility associated with On-Call Healthcare Inc.? If yes, what facility? Are you related to another facility employee? Yes    No Yes    No How did you learn about this position? State Employment Comission Agency Job Listing Current Employee Other: Advertisement School Job Line Internet Site Are you able to perform the essential, job related functions of the position for which you are applying with or without accomodations? Yes     No Please describe any accomodations necessary: Have you ever been convicted of a crime and/or released from confinement following a conviction following any criminal offense? Yes     No Arrest or charges that have been expunged need not be disclosed. If yes, give date, place, and nature of each such conviction: Date: Date: State: Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State: Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Nature: Nature: Are you presently charged with any violation of the law? Yes     No If yes, give date, place, and nature of each such charge: Date: Date:   State: Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State: Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Nature: Nature: EDUCATIONAL HISTORY School Name and Location of School Check Last Year Attended in School Degree or Certificate High School 9  10  11  12 Graduated/GED? Yes    No College/ University 1  2  3  4 Graduated? Yes    No College/ University 1  2  3  4 Graduated? Yes    No Graduate School 1  2  3  4 Graduated? Yes    No Nursing School Graduated? Yes    No Other From To     LICENSURE/CERTIFICATION Are you currently: Registered      Eligible for registry Profession in which you are licensed,registered, or certified: Professional title or society abbreviation: Select Title RN LVN CNA RRT PT LPTA CRTT Otr COTA SLP Original registration, certification, license number:      Date: California registration, certificaion, license number:      Date: Other state(s) registration, certification, license number:      Date:      Date: Other pending license:     Type: State: Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY  Expected Date: Clerical or other skills applicable to the position for which you are applying: Typing  wpm PBX Business Machines/Equipment: Proficient in Software: EMPLOYMENT HISTORY Please list all present and past employment beginning with your most recent position (including self-employment and military experience). Please provide the most recent 10 years of employment history. From To Company Phone Number Supervisor Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Salary Company Address May we contact them? Name while employed $ Yes    No Job Title City/State Reason for Leaving   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State   Nature of Duties From To Company Phone Number Supervisor Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Salary Company Address May we contact them? Name while employed $ Yes    No Job Title City/State Reason for Leaving   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State   Nature of Duties From To Company Phone Number Supervisor Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Salary Company Address May we contact them? Name while employed $ Yes    No Job Title City/State Reason for Leaving   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State   Nature of Duties From To Company Phone Number Supervisor Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Month 1 2 3 4 5 6 7 8 9 10 11 12 Year Salary Company Address May we contact them? Name while employed $ Yes    No Job Title City/State Reason for Leaving   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State   Nature of Duties PROFESSIONAL REFERENCES (Other than Relatives) Please provide two references who have good knowledge of your work. Name Position Address/City/State Phone (Home/Work) Years Known AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Select State Thank you for your interest in On-Call Healthcare Inc.. Please click the "Submit Application" button below to send us your responses. On-Call Healthcare Inc. is an equal opportunity employer and abides by all applicable federal and state laws prohibiting discrimination in employment because of race, color , sex, sexual orientation, religion, national origin, sexual orientatin, age, handicap, medical conditions or marital status.