PUC_Employment Application

Today's Date (Date of application)

Date

SOCIAL SECURITY NUMBER (Full):*

XXX-XX-XXXX

Last Name (Full)

First Name (Full)

Middle Name (Full)

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Mobile Number:

Email Address:

example@example.com

Are you prevented from lawfully becoming employed in this country (United States) because of Visa or Immigration status?

YesNo

Are you 18 years or older and eligible to work in the U.S.?

YesNo

Have you ever applied to Prestige Urgent Care?

YesNo

When did you last apply here?

How did you hear about us?

JobfairStaffing AgencyNewspaperEmployee

Who is the employee that referred you?

Are you currently active in the U.S. Military or Naval Service?

YesNo

Military Rank

Are you currently active in the U.S. National Guard or Reserves?

YesNo

What shift(s) are you applying for?

What position are you applying for?

When can you start work?*

Date

What is your desired salary?*

Did you graduate from High School or earn a GED?

YesNo

Name of High School attended & City/State:

Number of years attended:

Year of Graduation?

Diploma, Degree/Major/Certification obtained:

Did you graduate from College or an accredited post-secondary institution?

YesNo

Name of College or Post Secondary School:

Number of years attended:

Year of graduation

Diploma, Degree/Major or Certification obtained:

Did you attend an Allied Health Program or other Vocational Specialty Program?

YesNo

Name of Allied Health Program or other Vocational Specialty:

Number of years attended:

Year completed

Diploma, degree/major or certification obtained:

Have you attended any other type of healthcare related programs or training that may be relevant to the position you are applying for?

YesNo

Name of "other" health program or other vocational specialty:

Number of Years Attended

Year of Completion

Diploma, degree/major or certification obtained:

Do you hold a professional licenses (MD, RN, LPN, EMT, CMLA, PBT, etc)

YesNo

Indicate which licenses you have; Provide license number and expiration date(s):

Do you hold a professional certification (BLS, ACLS, PALS, CMA, RMA, PCT,CCA, etc)?

YesNo

Indicate any certifications you have:

May we contact any of your former employers you listed on your application?

YesNo

If no, please explain here:

Who can we contact in case of an emergency? (First and last name)*

Address of Emergency Contact:

Emergency Contact Phone Number:*

Reference #1 (first and last name)

First NameLast Name

Reference #1 Business Name or Company name.

Reference #1 Phone number

Please enter a valid phone number.

Number of years acquainted.

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.

SIGNATURE OF APPLICANT*

Clear

Attach Resume

License, Certifications, etc

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

APPLICANT'S PHYSICAL ADDRESS

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

APPLICANT QUESTIONAIRE

REFERRAL SOURCE

EMPLOYMENT DESIRED

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