Application for Employment

UCARE IS AN EQUAL OPPORTUNITY EMPLOYER. It is our policy to comply with all applicable federal, state, and local laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin, or other protected classification. ADA Statement: It is our policy to provide “reasonable accommodation” to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws.

Name (Last/First)

Date of Birth

Address

Phone number

Email address

Position you are applying to:

Select or enter value

Are you allowed to Work in the USA?

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Are you available to work 7 days a week/holidays?

Select

Are you looking for Part time or Full time?

Select

Are you willing to work overtime as required?

Select

Highest level of Education/School you attended

Are you skilled in basic computer programs?

Select

Are you a Veteran? Which branch?

Which languages are you fluent in?

Professional reference (name, phone number) #1

Professional reference (name, phone number) #2

Professional reference (name, phone number) #3

Have you been convicted of a felony?

Select

Date available to start

Desired salary (per hour)

Applicant’s Certification and Agreement

The information that I have provided on this application for employment is true and complete to the best of my knowledge. I understand that any false statements, omissions, or misstatements can be justification for refusal of employment, or if employed, result in termination of employment. I authorize this urgent care center to make an investigation of any of the facts set forth in this application, including obtaining a consumer report that includes credit and criminal history, and release from any liability both the urgent care center and those who supply reference information and/or verification. I understand and agree that this urgent care center reserves the right to establish and change any of the terms and conditions of my employment at its discretion at any time, as it deems appropriate. I understand and agree that, if employed, I may be required to submit to an alcohol or drug screening or medical examination at any time at the request of this urgent care center. I hereby consent to having the results of any alcohol or drug screening or medical examination I may be required to undergo disclosed to the urgent care center’s owners or managers. I authorize this urgent care center to release any and all information about myself, my employment record, or my employment status to any individual or organization the urgent care center deems worthy of receiving such information. Also, I release all parties form all liability for any damages that may result from furnishing this information. I certify that I have read all of the foregoing, understand the same, and do hereby voluntarily agree to all of the provisions of this authorization, certification, and agreement.

Full name, Last 4 digits of social security number

Send me a copy of my responses

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