Apply Now – Premier Urgent Care

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
Radiology
Technician
LPN/RNLPN/RN
Lab

Other (Indicate):

Tell us about yourself:

First Middle Last

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number

Are you over 18 years old?

Yes
No

Social Security Number

Email

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 U.S. on an unrestricted basis?

Have you been told the essential functions of the job or have you been shown a copy of the job description listing the essential functions of the job?

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

Have you ever been employed at Premier Urgent Care?

Dates of employment

Location

Reason for separation from employment.

Professional reference

Yes
No

Name*

Number*

Email*

Name*

Number*

Email*

Name*

Number*

Email*

Please indicate the hours you are available to work:

Day

Mon	Tues	Weds	Thurs	Fri	Sat	Sun	Holiday

Start:

Mon	Tues	Weds	Thurs	Fri	Sat	Sun	Holiday

Finish:

Mon	Tues	Weds	Thurs	Fri	Sat	Sun	Holiday

Do your prefer:

Part-Time
Full-Time?

Education

Type of School

Name of School	Location	Number of Years Completed	Major & Degree

Name of High School

Name of School	Location	Number of Years Completed	Major & Degree

Name of College

Name of School	Location	Number of Years Completed	Major & Degree

Name of Graduate School

Name of School	Location	Number of Years Completed	Major & Degree

Name of Bus. or Trade School

Name of School	Location	Number of Years Completed	Major & Degree

Name of Professional School

Name of School	Location	Number of Years Completed	Major & Degree

Computer Skills (Only for positions which require computer skills)

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

Windows
Microsoft Word
Microsoft Excel
Microsoft Publisher
Web Page Design/ Maintenance
E-mail
Internet
Other Please list:

Are you a veteran of the United States military service?

Yes
No

If yes, what branch?

If yes, Date Entered

Date Discharged

If yes, please describe any special skills or training acquired while in the service:

Other Special Skills

Please list other special skills you may have, e.g., fluency in other languages, licenses, special training required for the position for which you are applying, etc.

Professional References*

Dates Known	Relationship	Telephone Number

*

Dates Known	Relationship	Telephone Number

*

Dates Known	Relationship	Telephone Number

Work History

May we contact your present employer?

Yes
No

Most Recent Employer

Position	Start Date	End Date	Supervisor Name	Address	City/State/Zip	Telephone Number	Starting Salary	Starting Position	Reason for Leaving	Ending Salary	Ending Position

Employer

Position	Start Date	End Date	Supervisor Name	Address	City/State/Zip	Telephone Number	Starting Salary	Starting Position	Reason for Leaving	Ending Salary	Ending Position

Employer

Position	Start Date	End Date	Supervisor Name	Address	City/State/Zip	Telephone Number	Starting Salary	Starting Position	Reason for Leaving	Ending Salary	Ending Position

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:

Conviction will not necessarily disqualify an applicant for employment. If yes, please state nature of offense, dates, and disposition on back of this application.

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

Applicants Name (Print)

Signature*

Date