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Protocall Online Application

Thank you for your interest in employment opportunities with Protocall. This is our electronic application. Please fill in all the requested information. After agreeing to the terms and conditions listed, please type in the date and select the office that should receive the application.

Have you ever worked for Protocall before? Yes: No:
Social Security #:
Name:	Last First MI
Address:
City:
State:
Zip:
Home Phone:
Other Phone:
Email Address:
Have you resided at above address less than two years? Yes: No: If yes, please fill in the fields below
Prior Address:
City:
State:
Zip:
Emergency Contacts:
Name:
Relationship:
Home Phone #:
Work Phone #:

Are You Over Age 18? Yes: No:
Have you ever been convicted of a felony? Yes: No:
How were you referred to us?

NAME	ADDRESS	GRADUATE		DEGREE/CERT.
HIGH SCHOOL		Yes	No
COLLEGE		Yes	No
GRADUATE		Yes	No
OTHER/TECHNICAL		Yes	No

PROFESSIONAL LICENSES/CERTIFICATES
(* Health Care Applicants Only)

Protocall requires a copy of all current licenses/certifications for personnel documentation.
Verification of appropriate licensure is completed annually by state specific regulatory licensing agency.

TYPE	LICENSE/CERTIFICATE NUMBER	EXPIRATION DATE

EMPLOYMENT EXPERIENCE:

Current Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Title:
Dept.:
Salary:
Duties:
Reason for Leaving:
Supervisor/Title:
Telephone #:
Coworker Name:
Telephone #:
Coworker Name:
Telephone #:
Dates:	From: To:

Previous Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Title:
Dept.:
Salary:
Duties:
Reason for Leaving:
Supervisor/Title:
Telephone #:
Coworker Name:
Telephone #:
Coworker Name:
Telephone #:
Dates:	From: To:

Previous Employer:
Address:
City:
State:
Zip:
Telephone No.:
Job Title:
Dept.:
Salary:
Duties:
Reason for Leaving:
Supervisor/Title:
Telephone #:
Coworker Name:
Telephone #:
Coworker Name:
Telephone #:
Dates:	From: To:

I hereby understand that I am submitting this application via electronic mail. I hereby authorize release/review of my personal records to Protocall, its clients, state and government or accreditation agencies for the purpose of rendering service. I voluntarily consent to and authorize former or current employers, and its agents and employees, to furnish Protocall or any of its employees or agents any reference information concerning me, including achievement, wage history, performance, attendance, personnel history, disciplinary information and reason for separation of employment, relating to my employment with my former of current employer. I hereby release the former or current employer and its agents and employees from all liability for damages or claims, including but not limited to defamation, interference with contracts or prospective economic advantage or negligence I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information. I hereby give Protocall the right to conduct criminal background, drug and alcohol testing and credit reference information, if applicable. All statements made in this application are true to the best of my knowledge. I understand that any false statements or implementations made by me in this application or other documents will result in denial of employment or discharge. I understand that employment would be "at will" if hired. I have the right to terminate my employment at any time and that the Company retains a similar right. I also understand that only the President or Vice President of Protocall has the authority to change the foregoing or to enter into any agreement for employment for any period of time. Any such change or agreement must be made in writing. According to the policies of Protocall, an employee must, upon completion of an assignment, contact Protocall and request placement in a new assignment. If such contact is not made, Protocall will consider the employee to have voluntarily quit employment and further assignments may not be offered. In addition, if a claim for unemployment benefits is filed, failure to contact Protocall may affect the employee's benefit eligibility. We are an Equal Opportunity Employer.

Which Office would you like this application sent to?


By clicking "I Agree", I am confirming that all of the application information provided above is true and accurate. Any falsely providedinformation may result in legal action & termination of any employment placement.
I AGREE	DATE:
YOUR PERSONAL PASSWORD NUMBER:

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EOE (Equal Opportunity Employer)