Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resource Department.

Name
Last
First
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Address
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ANSWERING “YES” TO THESE QUESTIONS DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT, FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION, REHABILITATION AND POSITION APPLIED FOR WILL BE TAKEN INTO ACCOUNT.

Recent Employment History
SKILLS AND QUALIFICATIONS

Summarize any training, skills, licenses and/or certifications that may qualify you as being able to perform job related functions in the position for which you are applying.

EDUCATION BACKGOUND
Name and Location
REFERENCES

APPLICANT STATEMENT

I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from the employer’s service, whenever it is discovered.

I express authorize, without reservation, the employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and education institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding this employer, its agents, employees or representatives, for seeking gathering and using such information in the employment process and all other persons, corporation or organization for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limited or excusing any for employment on a basis prohibited by applicable local, state or federal law.

I understand and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.
If I am hired, I understand that I am free to resign at any time, with or without cause and with a two week notice, and the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract or employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are willing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I hereby AUTHORIZE and request any law enforcement agency to furnish bearer with criminal history and identity check information in their possession regarding me in connection with my employment in a critical position. I am willing that a photocopy of this authorization be accepted with the same authority as the original. I understand this AUTHORIZATION is to be part of the written employment application which I sign. I understand that Quality Urgent Care positions that are designated critical require background checks for the purpose of evaluating me for employment, promotion, reassignment, reclassification, transfer, or retention as an employee.

Statement
I certify that I have read, fully understand and accept all terms of the forgoing Application Statement