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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

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Have You Ever Worked At This Company?
Are You At Least 17 Years of Age?
Are You Willing to Work 9AM to 7PM?
Are You Willing to Work 8AM to 8PM?
Are You Willing to Work Overtime?
Have you ever been convicted of a felony?

REFERENCES

Please list three professional references.

Upload File

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

Section 2

PREVIOUS EMPLOYMENT

May we contact your previous supervisor for a reference?
Employer #2 Supervisor
May we contact your previous supervisor for a reference?

EDUCATION

Did You Graduate?
Did You Graduate?
Did You Graduate?

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.

Application Accepted

Thanks for Applying!