subject_line

Employment Application

Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com, 28000 Woodward Ave., Royal Oak, MI 48067

Which position are you applying for? *

Your Contact Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Daytime Phone Number * 🛈

Evening Phone Number * 🛈

Are you 18 years or older? *

Yes

Date you can start * 🛈 +

Do you have a shift preference? *

What type of employment are you looking for? *

Full Time

Part Time

Contingent

Per Diem

How far are you willing to travel for work? *

Hourly Wage Desired *

Annual Salary Desired *

Are you able to perform the essential job functions associated with the job for which you have applied without accommodation for a protected disability or religious practice?

Note: Timeliness and good attendance are essential functions for all jobs. *

Yes

Is there an accommodation that would permit you to perform the function? *

Yes

Please state what the accommodation may be *

Are you legally authorized to work in the U.S for any employer?

Note: Proof of identity and eligibility will be required upon employment *

Yes

Are you currently employed? *

Yes

May we contact you current employer? *

Yes

Have you previously applied at HealthCall? *

Yes

Please provide date: * 🛈 +

Have you ever worked at HealthCall? *

Yes

Please provide date: * 🛈 +

What was your reason for leaving? *

Do you have any relatives employed at HealthCall? *

Yes

If yes, please state their name and relationship. *

How did you hear about this employment opportunity? *

Employee	HealthCall Website
HealthCall Open House	Exterior Signage
Classified Ad	College/University Ad
Mailing/Postcard	Job Fair
Social Media	ZipRecruiter
Indeed	Other Other

Employee First Name *

Employee Last Name *

If you found HealthCall on social media, please specify which platform (i.e. Facebook, Twitter, etc.). *

If you found HealthCall via a college/university ad or job fair, please specify. *

Are you currently under a legal agreement such as a non-compete agreement or a settlement agreement, which might prevent you from working at HealthCall or from rendering services to specific HealthCall clients? *

Yes