FirstCall HomeCare
Employee Application

Personal Information

Professional Information

License/Certification

Education

Diploma / Technical
College
Graduate School
Areas of clinical experience

Availablity

If you indicate no, you will be responsible for contacting us with your shift requests.

Employment History





Work Referrals

Work Referral #1
Work Referral #2
Work Referral #3

Background Information

AGREEMENT, AUTHORIZATION, AND CONSENT FOR RELEASE OF BACKGROUND INFORMATION

I Understand that in conjunction with my application for employment, work to be performed under contract, promotion. reassignment, and/or retention, FirstCall Home Care, may use the services ofan outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing. work history and qualifications. This agency will provide a written report of its findings to Firstcall Home Care. I do hereby give Firstcall Home Care permission to release the results ofmy drug screen, background check and employment references to any facilities I may work at through Firstcall Home Care. I understand the information will be kept confidential and only used to verify eligibility to work.
FirstCall Home Care will utilize various resources of information it deems appropriate including any and all injuries in compliance with the FEDERAL ADA ACT, DEPARTMENT OF MOTOR VEHICLE RECORDS. CRIMINAL CONVICTION RECORDS, CURRENT AND FORMER EMPLOYERS,MILITARY RECORDS. EDUCATION RECORDS. and PROFESSIONAL AND PERSONALREFERENCES. I agree. authorize and consent to the release and disclosure ofany and all information but not limited to the above to Firstcall Home Care and its outside research agency.
I agree, authorize and consent to the procurement ofa consumer credit report and/or investigative consumer report and understand that it may contain information about my credit worthiness. credit standing, credit capacity, character. general reputation, personal characteristics and mode of living. This authorization in original or copy form shall be valid for my term ofemployment fiom the date indicated next to my signature. According to the FAIR CREDIT REPORTINC ACT, I will be notified by Firstcall Home Care, if employment is denied because of informalion obtained by the consumer reporting agency. Additionally, I understand that ifrequested within 60 days. I will be given a full and accurate disclosure as to the nature and substance ofall information provided to Fintcall Home Care. I further undersland lhat I may request to Firstcall Home Care, 14480 E 42"d Street South, lndependence, MO 64055. I understand that residents ofall states Nill automatically receive a copy ofthe report if an adverse action is taken regarding the emplolment application. or upon request as outlined herein.
LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSTIVE INDENTIFICATION PURPOSE REQUIRE THE FOLLOWINC INFORMATION WHEN CHECKING PUBLIC RECORDS IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER INFORMATION.

I agree, AGREEMENT, AUTHORIZATION, AND CONSENT FOR RELEASE OF BACKGROUND INFORMATION