Employment Application

You must complete and submit an application for employment to be considered. * All fields marked in bold and with an asterisk are required.

If employed the following must be provided to Nurses on Call

1. Drivers License
2. Social Security Card
3. Proof of car insurance
4. 10 Year Driving Record
5. Recent PPD (TB test record)
6. Any Certificates (CPR, etc)
7. Nursing License (if applicable)
8. SLED background check
9. Verifiable character references

Personal Information

Position Applying For *
Last Name *
First Name *
Maiden Name/Alias
DOB (MM/DD/YY)
Street Address *
City *
State * Zip *
Telephone * ex: 555-555-5555
Cell Phone ex: 555-555-5555
Email Address *
Emergency Contact *
Emergency Phone No. * ex: 555-555-5555
Emergency Mailing Address *
Relationship *
Physician *
Physician Phone Number* ex: 555-555-5555
Salary Required (per hour) * $
Days/Hours available for work *

Education

NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETED MAJOR & DEGREE
High School
College
Business or Trade School
Professional School

General Information

Please summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. *

Former Employer (List last one first)

Dates (MM/DD/YY) From To / Present
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Former Employer (2)

Dates (MM/DD/YY From To
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Former Employer (3)

Dates (MM/DD/YY From To
Employer Name
Employer Address
Reference Name
Reference Telephone
Salary $
Position
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Character References (other than relatives or previous employers)

Name * Phone No.(s) *
ex: 555-555-5555		 Years Known* How Acquainted*

Other Information

How did you hear about Nurses on Call? *
List your personal goals: *

Driver's license

Do you have a driver's license? *
What is your means of transportation to work? *
Driver's license number
State of issue Operator Commercial (CDL) Chauffeur
Expiration date

Criminal Record

Have you ever been convicted of a crime? *

If yes, explain number of conviction(s), nature of offence(s) leading to conviction(s), how recently such offence(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.
Any felonies? Yes No

Miscellaneous

I certify that I have dependable transportation. *

I certify that I have a telephone. *

I certify that I have an insured vehicle.*

Counties

Please select every county in which you intend to provide services.:

Tip: To select multiple locations, hold down the Ctrl key while clicking each county.

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of my background through SLED checks and all other information provided and release Nurses on Call from all liability from any damage that may result from using such information. I also understand and agree that no representative of Nurses on Call has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing, unless in writing and signed by an authorized Nurses on Call representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans With Disabilities Act (ADA) and other relevant federal and state laws. *
Do you agree with the authorization statement?