Application for Employment

EQUAL OPPORTUNITY EMPLOYER. It is our policy to comply with all applicable federal, state, and local laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification.

ADA Statement: It is our policy to provide “reasonable accommodation” to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws.

What position are you applying for?

Front Desk Medical Assistant LPN/RN Radiology Tech

What location are you applying for?

Alexandria Pineville Jena Natchitoches

Other:

First Name

Middle Name

Last Name

Street Address

City

State/Province

ZIP / Postal Code

Phone Number

Are you over 18 years old?

Yes No

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. All offers of employment are subject to verification of the applicant’s identity and employment authorization. It will be necessary to submit such documents as are required by law to verify your identification and employment authorization upon employment.

Are you authorized to work in the United States on an unrestricted basis?

Yes No

Have you been told the essential functions of the job, or have you been shown the job description?

Yes No

Can you perform these essential functions with or without reasonable accommodation?

Yes No

Have you ever been employed at Premier Urgent Care?

Yes No

Dates of Employment

Location

Reason for Separation

Start Time

End Time

Which do you prefer?

Part-Time Full-Time

Name

Location

Number of Years Completed

Major/Degree

Name

Location

Number of Years Completed

Major/Degree

Name

Location

Number of Years Completed

Major/Degree

Name

Location

Number of Years Completed

Major/Degree

Name

Location

Number of Years Completed

Major/Degree

Check off computer skills in which you are proficient (any version)

Are you a veteran of the United States military service?

Yes No

If yes, what branch?

Date Entered

Date Discharged

Describe any skills or training acquired while in service

Other special skills

Name

Dates Known

Relationship

Number

Name

Dates Known

Relationship

Number

Name

Dates Known

Relationship

Number

May we contact your present employer?

Yes No

Date Available to Start

Desired Wage or Salary

Per ?

Are you willing to work overtime as required?

Yes No

Have you ever been convicted of a felony?

Yes No

Have you ever been terminated or asked to resign?

Yes No

Has your employment ever been terminated by mutual agreement?

Yes No

Have you ever been given the choice to resign rather than be terminated?

Yes No

If you answered yes to any of these questions, please explain

Applicant’s Certification and Agreement The information that I have provided on this application for employment is true and complete to the best of my knowledge. I understand that any false statements, omissions, or misstatements can be justification for refusal of employment, or if employed, result in termination of employment. I authorize this urgent care center to make an investigation of any of the facts set forth in this application, including obtaining a consumer report that includes credit and criminal history, and release from any liability both the urgent care center and those who supply reference information and/or verification. I understand and agree that this urgent care center reserves the right to establish and change any of the terms and conditions of my employment at its discretion at any time, as it deems appropriate. I understand and agree that, if employed, I may be required to submit to an alcohol or drug screening or medical examination at any time at the request of this urgent care center. I hereby consent to having the results of any alcohol or drug screening or medical examination I may be required to undergo disclosed to the urgent care center’s owners or managers. I authorize this urgent care center to release any and all information about myself, my employment record, or my employment status to any individual or organization the urgent care center deems worthy of receiving such information. Also, I release all parties form all liability for any damages that may result from furnishing this information. I certify that I have read all of the foregoing, understand the same, and do hereby voluntarily agree to all of the provisions of this authorization, certification, and agreement.

Premier Urgent care is an at-will employer as allowed by applicable state law. This means that regardless of any provision in this application, if hired, the company or i may terminate the employment relationship at any time, for any reason, with or without cause or notice. Nothing in this application or in any document or statement, written or oral, shall limit the right to terminate employment at-will. No officer, employee or representative of the company is authorized to enter into an agreement - express or implied with me or any applicant for a specified period of the time unless such an agreement is in a written contract signed by the president / CEO of the company . If hired, I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time except that it will not modify its policy of employment at will.

This application will be considered active for a maximum of sixty (60) days. If you wish to be considered for employment after that time, you must reapply”.

“Do not sign this application until you have read all of the information contained in the application.

I have read the above statements before signing

Yes No

Applicant's Signature

Date

Application for Employment

Application for Employment

Alexandria

Online Check-In Information:

Pineville

Online Check-In Information:

Jena

Online Check-In Information:

Natchitoches

Online Check-In Information: