Employment Application

Date
First Name
Middle Name
Last Name
Preferred Name/Nickname
Street Address
Apartment/Unit #
City
State
Zip Code
Home Phone
Alternate/Work Phone
Email Address

PLEASE PLACE A CHECK BY YOUR RESPONSE OR PROVIDE THE APPROPRIATE INFORMATION

Are you interested in: Full TimePart TimeTemporary
What schedule would you prefer? WeekdaysWeekendsEveningsNights
How did you hear about the position? Classified AdFriend (Name)RadioInternet
Desired Pay:
Hourly Pay
Annual Pay
Desired
When are you able to start work?
In what local area do you prefer to work?
Position desired:

PLEASE CHECK YES OR NO TO THE FOLLOWING:

Are you authorized to work in the United States? yesno
Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Convenient Urgent Care will verify the status of every individual offered employment with the Company. In this connection, all offers of employment are subject to verification of the applicant’s identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization.
Are you under 18 years of age? yesno
If yes, can you furnish a work permit? yesno
Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation? yesno

Convenient Urgent Care is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, Convenient Urgent Care complies with applicable state and local laws governing non-discrimination in
employment in every jurisdiction in which it maintains facilities. Convenient Urgent Care also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

PLEASE LIST YOUR WORK EXPERIENCE BELOW (MOST RECENT JOB FIRST)

Massachusetts applicants may include any verified work performed on a volunteer basis.

COMPANY NAME
YOUR POSITION and TITLE
FROM
NO. & STREET
SUPERVISOR’S NAME, TITLE and POSITION
CITY
STATE
ZIP CODE
SUPERVISOR’S TELEPHONE NUMBER
TO
TELEPHONE NUMBER
TERMINATION
VOLUNTARYINVOLUNTARY
REASON
BRIEFLY DESCRIBE YOUR MAJOR DUTIES AND REASON(S) FOR TERMINATION

COMPANY NAME
YOUR POSITION and TITLE
FROM
NO. & STREET
SUPERVISOR’S NAME, TITLE and POSITION
CITY
STATE
ZIP CODE
SUPERVISOR’S TELEPHONE NUMBER
TO
TELEPHONE NUMBER
TERMINATION
VOLUNTARYINVOLUNTARY
REASON
BRIEFLY DESCRIBE YOUR MAJOR DUTIES AND REASON(S) FOR TERMINATION

COMPANY NAME
YOUR POSITION and TITLE
FROM
NO. & STREET
SUPERVISOR’S NAME, TITLE and POSITION
CITY
STATE
ZIP CODE
SUPERVISOR’S TELEPHONE NUMBER
TO
TELEPHONE NUMBER
TERMINATION
VOLUNTARYINVOLUNTARY
REASON
BRIEFLY DESCRIBE YOUR MAJOR DUTIES AND REASON(S) FOR TERMINATION

EDUCATION

HIGH SCHOOL OR PREP
COLLEGE
COLLEGE OR GRADUATE
OTHER

PROFESSIONAL DESIGNATIONS

PROFESSIONAL LICENSES

REFERENCES: Please list three professional references

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION

I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application.

My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company’s employ.

I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking.

I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be “at will” and either the Company or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process
affecting its employees.

References: I hereby authorize the company and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee
of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that a contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment with the client, I agree to notify the company immediately should I be offered direct employment by a client (or by referral of the client to any subsidiary or affiliated company), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended.

Signature



Date
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