Employment

 

To The Applicant: Selma Urgent Care is an equal opportunity employer and will not discriminate against any employee or applicant on the basis of race, color, religion, sex, age, national origin, citizenship status, or disability.  No question on the application is asked for the purpose of limiting or excluding any applicant’s consideration for employment in any manner prohibited by law.  The completing of the application in no way guarantees the applicant that he or she will receive a pre-employment interview or any other further consideration for employment by Selma Urgent Care. We appreciate your interest in seeking employment.  This application is to be active for a period of 60 days only. 

 

Yes

No

Have you ever been convicted of or plead guilty to a misdemeanor or felony offense other than minor traffic violations?  

Have you been released from confinement following a conviction of any misdemeanor or felony offense?

Are you presently charged with any misdemeanor or felony violations of law other than minor traffic violations?

 

If your response was “yes”, please explain fully to include giving the date, place and circumstances.  The existence of a conviction will not necessarily preclude you from employment; the nature of the crime and its relationship to the position applied for, the degree of rehabilitation of the applicant and the time elapsed since the crime or release from confinement will all be considered.

 

 

Read this section prior to providing signature below

 

I understand that if employed, my employment will be by mutual consent for an indefinite term and may be terminated at any time and for any reason , with or without cause, at my option or at Selma Urgent Care’s option.  I understand that no manager or representative of Selma Urgent Care, other than the President of Selma Urgent Care has any authority to enter into any agreement for employment for any specified foregoing either now, in the past, or in the future.  I further understand that even such an agreement must be in writing and signed by the President for it to be binding on either myself or Selma Urgent Care. 

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete.  I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge  even if discovered at a later date. 

I understand that all statements made by me in connection with my employment may be verified by Selma Urgent Care.  I authorize Selma Urgent Care to contact my prior employers, current employer if so indicated on the application, and other sources of information, regarding my background.  I hereby authorize and direct each such employer and other sources of information to answer any and all questions regarding my prior employment and background.  I hereby indemnify Selma Urgent Care, each contacted employer, and each of the other sources of information contacted, and agree to hold them harmless from any claims arising from this authorization and direction. 


I understand that any offer of employment that I may receive will be contingent upon successful completion of a pre-employment physical examination.  I understand that as a condition of my acceptance for employment I will be required to successfully pass the test for illegal drugs, and that my refusal to submit for such testing will eliminate me from further consideration for employment.  I further understand that if I am hired I may be required from time to time to undergo drug and alcohol testing and that my refusal to submit to such testing will result in termination of my employment on grounds of insubordination.

I hereby certify that I (a) have never been excluded, suspended, debarred, or otherwise deemed ineligible to participate in Federal and/or State health care programs; and (b) have never been convicted of a criminal offense related to the provision of health care items or services and have not been reinstated in the health care programs after a period of exclusion, suspension, debarment, or ineligibility; and (c) authorize Selma Urgent Care to review, on an ongoing basis while an employee of Selma Urgent Care , pertinent government databases to ensure the eligibility status of employee as required by relevant state and federal mandates.

 

Candidate’s/Applicant’s Signature:                                  Date:


Position Applied For:

   
Application Information
Last Name First M.I. Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Date Available

Cell Phone

Desired Salary

Position Applied for

Are you a citizen of the United States?  Yes   No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for this company? Yes No

If so, when?

Have you ever been convicted of a felony? Yes No

If yes, explain

 
Education

High School

Address

From

To

Did you graduate? Yes No

Degree

College

Address

From

To  

Did you graduate? Yes No

Degree

Other

Address

From

To

Did you graduate? Yes No

Degree

 
References

Please list three professional references.

 

Full Name 

Relationship

 Company 

Phone

Address    
Full Name 

Phone

Company  

Relationship

Address   
Full Name 

Relationship

Company  

Phone

Address   
 
 
Previous Employment
Company Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving 

May we contact your previous supervisor for a reference? Yes No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference? Yes No

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference? Yes No

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.

Signature

Date

 

Military Service

Branch

From To

Rank at Discharge

Type of Discharge

If other than honorable, explain