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Application for Employment

Fill out application form completely. If questions are not applicable, enter "NA" where possible. Be sure to sign when completed.

StatCare Urgent Care Clinic is an Equal Opportunity Employer and does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. Resumes will not be accepted in lieu of applications. This application becomes public record and is subject to disclosure.

Section 1

First Name

M.I.

Last Name

Date of Birth

Address

Apartment/Unit #

City

Zip

Primary Phone #

Secondary Phone #

Available to Start Date?

Desired Hourly Rate

Have You Ever Worked At This Company?

Yes

If so, when?

Do you have any relatives working for this agency? If so, list names and relationships:

Are You At Least 17 Years of Age?

Yes

Are You Willing to Work 9AM to 7PM?

Yes

Are You Willing to Work 8AM to 8PM?

Yes

Are You Willing to Work Overtime?

Yes

Have you ever been convicted of a felony?

Yes

If yes, explain:

REFERENCES

Please list three professional references.

Reference #1

Relationship

Company

Phone

Address

Reference #2

Relationship

Company

Phone

Address

Reference #3

Relationship

Company

Phone

Address

Upload CV/Resume Here:

Upload File

Section 2 You may skip Section 2 if you have a CV/Resume on file. After your upload, please continue on to Section 3.

PREVIOUS EMPLOYMENT

Employer #1

Phone

Supervisor

Address

Job Title

Dates

Starting Salary

Ending Salary $

Responsibilities

Reason For Leaving

May we contact your previous supervisor for a reference?

Yes

Employer #2

Phone

Supervisor

Address

Job Title

Dates

Starting Salary

Ending Salary $

Responsibilities

Reason For Leaving

Employer #2 Supervisor

Yes

Employer #3

Phone

Supervisor

Address

Job Title

Dates

Starting Salary

Ending Salary $

Responsibilities

Reason For Leaving

May we contact your previous supervisor for a reference?

Yes

EDUCATION

High School

Address

Dates Attended

Diploma

Did You Graduate?

Yes

College/University

Address

Dates Attended

Degree

Did You Graduate?

Yes

Other Education

Address

Dates Attended

Degree

Did You Graduate?

Yes

Special skills/training: Summarize any job-related training, skills, computer knowledge, licenses, certificates, and any other information you believe is relevant to your qualifications for this job

Section 3 DISCLAIMER AND SIGNATURE

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED

1. I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I understand that any misstatement, falsification, or omission of information may be grounds for refusal to hire or, if hired, termination.

2. I understand that as a condition of employment, I will be required to provide legal proof of authorization to work in the U.S.

3. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.

Your Signature

Signature

Application Accepted

Thanks for Applying!