Application for employment at Urgent Care Clinical Trials

Contact Information
Name*
First Middle Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

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Current Employment
Current Company*
Phone*
Position*
Immediate Supervisor*
Date started*
MM slash DD slash YYYY
Date finished (current date if still employed)*
MM slash DD slash YYYY
Current Employer Address*
Street Address Address Line 2 City State ZIP Code
Starting Salary*
Current Salary*
May we contact this employer?*
- Yes
- No
Reason for leaving*
Job Responsibilities*

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Employment History
Previous Company
Phone
Position
Immediate Supervisor
Date started
MM slash DD slash YYYY
Date finished
MM slash DD slash YYYY
Employer Address
Street Address Address Line 2 City State ZIP Code
Starting salary
Finishing salary
May we contact this employer?
- Yes
- No
Reason for leaving
Job Responsibilities
Extended Employment History
(Hit the plus sign to the right to add additional employer)
Employer Start Date End Date Salary Start Salary End

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References
Please provide three (3) references for us to contact.*
Name Relationship How many years Phone

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Finish
Have you even been convicted of, pled guilty to, or pled nolo contendere to a crime?*
- Yes
- No
Please give details ( A conviction will not necessarily disqualify an applicant for the position sought.)*
Do you currently have any charges pending?*
- Yes
- No
Please give details ( A conviction will not necessarily disqualify an applicant for the position sought.)*
Legal Stuff
Terms & Conditions
I authorize Urgent Care Clinical Trials herein the "Company", to make such investigations and inquiries of my personal employment, independent contract work, education, certifications and other related matters as may be necessary in arriving at an employment decision or for the purposes of an independent contractor agreement. I hereby release employers, schools and individuals from all liability in responding to inquiries in connection with my application.

If an offer of employment or Independent Contractor work is extended the Company will perform a reference and background check, and will require a drug test prior to the start of employment or Independent Contractor Work. An offer of employment or start of Independent Contractor Work is contingent upon the successful completion of this process.

The Company relies upon the accuracy of information contained in the application, as well as the accuracy of other data presented throughout the hiring process and employment or Independent Contractor Work. Any misrepresentations, falsifications, or material omissions in any of this information or data may result in the exclusion of the individual from further consideration for employment or Independent Contractor Work or, if the person has been hired, termination of employment or commencement of Independent Contractor Work, regardless of the date of discovery. I certify that all answers and statements on this application are true and complete to the best of my knowledge.
Acceptance*
- I agree to the Terms and Conditions
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Careers

Application for Work

Step 1 of 8 - Contact Information

Contact Information

Position

Education

Current Employment

Employment History

Extended Employment History

Experience

References

Finish

Legal Stuff

Terms & Conditions

Employer	Start Date	End Date	Salary Start	Salary End

Name	Relationship	How many years	Phone