employment application
Urgent MedCare is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability or any other characteristic protected by law.
Date
Position Applied For:
Introductory Information:
First Name Middle Name Last Name
Social Security Number
Address
City State Zip/Postal Code
Home Phone Cell Phone Alternate Phone
How long at current address?
Application Questions:
Type of Work Preferred: Part-Time Full-Time
Salary Desired Date Available to Start
If hired, can you provide documents required to establish your eligibility to work in the U.S. Yes No
Are you 18 years of age or older? Yes No
How were you referred to Urgent MedCare?
Education:
High School or Last Grade Complete:
Name of School
College or Technical School:
Name of School Address of School City State Zip Course of Study: Number of Years Completed: Degree/Diploma Did you graduate?Yes No If yes, what year?
Other Schooling or Training:
Name of School Address of School City State Zip Course of Study: Number of Years Completed: Degree/Diploma Specialized Training, Skills, and Extra-Curricular Activities:
Military Experience:
Branch of Service: From to Rank/Type of Service Special Training/Experience Have you ever received dishonorable discharge from any U.S. Armed Services? Yes No Explanation
Record of Employment:
Are you currently employed? Yes No If yes, may we contact your present employer? Yes No
*List positions starting with the most recent*
Employer
Employer Address City State Zip Position/Title Supervisor Start Date Ending Date Beginning Salary Ending Salary Reason for Leaving
Qualifications:
CPR Certified? Yes No Expiration Date
Work-Related References: (Do not include relatives)
Name Occupation Years Known Primary Phone Alternate Phone
Statement (Please read this statement carefully before signing this application):
I hereby certify that the information contains in this application is true and accurate to the best of my knowledge. I authorize URGENT MEDCARE to check any and all statements and references contained in this document for accuracy and completeness. I authorize the references listed as well as my previous employers to release information pertinent to this application. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to URGENT MEDCARE or any of its agents, employees or representatives. I understand that any misrepresentation, omission of information or falsification on this application may result in my failure to receive an offer or if hired my dismissal from employment.
I understand that offers to employment are conditioned on satisfactory proof of identity and legal eligibility to work in the United States.
I understand that, if I am hired, the company may terminate my employment at any time, with or without cause, and with or without prior notice. I understand that, except by written agreement signed by the president of the company, no manager, supervisor, employee or other company representative has any authority (I) to promise employment for a particular length of time, or (II) to make any other promises or representations about my future employment with the company.
Any applicants that further pursue and/or accepting employment with URGENT MEDCARE agrees to the following ARBITRATION CLAUSE.
All controversies, grievances, claims, and or accepting employment with URGENT MEDCARE shall be determined and adjudged by binding arbitration which shall be conducted by an independent arbitrator who shall be certified by the American Arbitration Association. I further agree the said arbitration shall be a complete defense to any suit, action, or proceeding instituted in any federal, state, or local court or before any administrative agency with respect to any other controversies grievances, claims and/or charges which may arise during my employment relationship with URGENT MEDCARE.
Including, but not limited to, claims which may be brought under the Age Discrimination Employment Act (ADEA), the American with Disabilities Act (ADA) or any other Title VII claim under the Civil Right Act. I further agree and stipulate that binding arbitration shall be the sole and exclusive remedy for any claims against URGENT MEDCARE arising from employment. Each party shall be responsible for the payment of its own attorney’s fees and one half of all costs associated with retaining an arbitrator to resolve any dispute or claim.
I understand this application will be active for a period of 90 days; after that time, if I wish to be considered for employment, I must submit a new application. I certify that all the statements in this completed application are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal to hire.
Initials