• APPLICATION FOR EMPLOYMENT

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  • PERSONAL INFORMATION

  • APPLICANT'S PHYSICAL ADDRESS

  • APPLICANT'S MAILING ADDRESS (IF Different from Physical):

  • APPLICANT QUESTIONAIRE

  • REFERRAL SOURCE

  • EMPLOYMENT DESIRED

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  • HIGH SCHOOL EDUCATION

  • COLLEGE EDUCATION

  • ALLIED HEALTH PROGRAMS

  • OTHER ALLIED HEALTH PROGRAMS

  • LICENSED APPLICANTS

  • PROFESSIONAL CERTIFICATIONS

  • PREVIOUS EMPLOYMENT

  • EMERGENCY CONTACT INFORMATION

  • PROFESSIONAL REFERENCES

  • APPLICANT ATTESTATION

  • PRESTIGE URGENT CARE is an EQUAL OPPORTUNITY EMPLOYER All practices of recruiting. hiring, promotion, transfer, wage and salary administration, benefit and terminations are administered without regard to race, color, creed, sex, religion, national origin, disability, age, veteran status or any and all other unlawful biases regarding federal, state, and local laws. Further, we are committed to providing a work environment that prohibits, in any form, unlawful harassment. To be consideredfor employment, all applicants must fill out this form completely. ("See resume" is not an appropriate response This application will be considered, but its receipt does not imply that the applicant will be employed by the company. This form becomes a permanent part of your employment record if you are hired.

    "I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION is TRUE AND COMPLETE, AND UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME."

    IN CONSIDERATION OF MY EMPLOYMENT, IAGREE TO CONFORM TO THE COMPANY'S RULES AND REGULATIONS, AND AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE. AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY'S OPTION.I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT'S OWNER OR DESIGNEE, AND THEN ONLY WHEN IN WRONG AND SIGNED BY THE OWNER OR DESIGNEE, HAS ANY AUTHORITY TO ENTERINTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.

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