Employment Application

Legal Last Name*

Legal First Name*

Middle Initial

May we contact you via E-mail?

Yes

No

If so, please provide your E-mail address*:

Social Security Number*

Date Available to start work*

Home phone number*

Message/Mobile number*

Address (number, street, apartment number)*

City*

State*

Zip*

Were you previously employed/interviewed by 8-2-8 UC?

Yes

No

If YES, Date:

From

To

Position:

location:

If no, how were you referred?

Advertisement (specify):

Employment Agency (Company):

Employee Referral (Name of Employee):

School:

Other (Specify):

CAN YOU, AFTER EMPLOYMENT OFFER, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES?

Yes

No

(In accordance with the immigration Reform and Control Act of 1986, any offer of employment is conditioned upon satisfactory proof of applicant’s identity and legal ability to work in the United States.)

Are you authorized to work for all U.S. employers?

Yes

No

Do you have reliable transportation?

Yes

No

Are you at least eighteen years of age?

Yes

No

(If less than 18 yrs., you will need to provide a work permit and/or age certificate upon offer of employment)

Have you ever been convicted of a felony?

Yes

No

If YES, please explain: (such a conviction will not necessarily disqualify you from employment with Client Name. Please attach an additional sheet if necessary).

Job Interest

Education Information

Type of school	Name and Location	Years Completed	Major Course of Study	Graduated (Yes or No)	Degree
High School
College/University
Graduate School
Technical/Business

Please list any job related professional, trade, business or civic activities, organizations, and associations in which you participated, or of which you are a member. (You may omit those that indicate race, color, religion, political affiliations, national origin, ancestry, disability, marital status, sex, or age.)

Job-Related Skills or Experience

List any job related skills or experience that would qualify you for the position for which you are applying:

Languages Spoken: English, Spanish or other

Employment History

Starting with your most recent job, accurately list ALL jobs you have held in the past ten (10) years. Give correct addresses and telephone numbers. Include volunteer experience.

1.

Name of current/most recent employer:

Position Held:

Employer’s address (number/street):

City:

State:

Zip:

Dates Employed:

From

To

May we contact your present employer?

Yes

No

Position (starting):

$

Final salary: $

Hourly

Weekly

Monthly

Yearly

Reason for leaving:

Telephone Number:

Supervisor (name and title):

2.

Name of current/most recent employer:

Position Held:

Employer’s address (number/street):

City:

State:

Zip:

Dates Employed:

From

To

May we contact your present employer?

Yes

No

Position (starting):

$

Final salary: $

Hourly

Weekly

Monthly

Yearly

Reason for leaving:

Telephone Number:

Supervisor (name and title):

3.

Name of current/most recent employer:

Position Held:

Employer’s address (number/street):

City:

State:

Zip:

Dates Employed:

From

To

May we contact your present employer?

Yes

No

Position (starting):

$

Final salary: $

Hourly

Weekly

Monthly

Yearly

Reason for leaving:

Telephone Number:

Supervisor (name and title):

References

Please provide the names, addresses, and telephone numbers of at least two (2) professional references who are not related to you.

1.

Name

Title

Address

Telephone Number

2.

Name

Title

Address

Telephone Number

3.

Name

Title

Address

Telephone Number

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING BELOW

We greatly appreciate your interest in our organization. Please be advised that applicants are considered for all positions without regard to race, age, color, sex, religion, national origin, disability, marital or veteran status. For consideration for employment with us, the application must be completed in its entirety and signed by you.

This application will remain open for consideration for the position for which you applied for ninety (90) days from today’s date. If you wish to be considered for this position or another position after ninety days from this date, you will need to complete and submit another application.

I certify that the answers given by me are true and correct without omissions of any kind whatsoever, and that intentional falsification of information given will be grounds for disciplinary action, up to and including termination.

I understand any offer of employment may be contingent upon a credit, criminal or other types of background checks, including a drug screening. I hereby authorize all references and former employers listed on my employment application to give the company any and all information concerning my previous employment and any pertinent information they might have, personal or otherwise, and release all parties from any claims, causes of action, or liability from damages that may or could result in furnishing such information to the company.

I understand that if hired, the employment relationship is at-will. This means that either 8-2-8 Urgent Care or I may terminate the employment relationship at any time, for any or no reason.

UNDER CALIFORNIA LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

Signature of Applicant:*

Date:*

Personal Information

If YES, Date:

If no, how were you referred?

Job Interest

Wage/Salary desired:

Education Information

Job-Related Skills or Experience

Employment History

1.

Dates Employed:

Position (starting):

2.

Dates Employed:

Position (starting):

3.

Dates Employed:

Position (starting):

References

1.

2.

3.

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING BELOW

8-2-8 URGENT CARE IS AN EQUAL OPPORTUNITY EMPLOYER