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We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status. If you need an accommodation or assistance to complete this application or proceed through the application process due to disability, please advise us by calling us at 1-501-279-9000.
 

Employment contingent on passing a background check, and drug test.

Fields marked with ''*' are required fields
 
Section 1
*How Did You Learn About Us?
              
Section 2
Name

*Last *First Middle

*Street Address

*City                            State         

*Zip Code          

*Phone Number       Secondary Phone Number

*E-mail Address

Section 3
General Information

Position applying for:           Location:

Best time to contact you at home is:
If you are under 18 years of age, can you provide required proof of your eligibility to work?

n/a
Have you ever filed an application with us before? If yes, please give date (mm/yyyy).
Have you ever been employed with us before? If yes, please give date (mm/yyyy).
Do any of your friends or relatives currently work at Primecare?
Have any of your friends or relatives worked at Primecare in the past?
Are you currently employed?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment
Date available for work  (mm/yyyy)
What is your desired salary range?
Are you available to work:
Are you currently on "lay-off" status and subject to recall?
Can you travel if a job requires it?
Section 4
Education
  Name and
Address of School		 Course of
Study		 No. of
Years
Completed		 Diploma/
Degree
Elementary
School
High School
Undergraduate
College
Graduate/
Professional
Other
Describe any specialized training, apprenticeship, or skills.
 

Certification/license/registration Number

Expiration Date

Did you serve in the U.S. Armed Forces?

Branch

Dates of Service: From

To

Rank at the End of Service

Describe any job-related training received in the United States military.

Section 5
Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
My past employers are noted below, starting with the most recent first.
1. Employer
 
Street Address

City State Zip Code

Supervisor
Job Title   
Work Performed
Dates Employed — From
To
Hourly Rate/Salary — Starting Final
Reason for Leaving

2. Employer
 
Street Address

City State Zip Code

Supervisor
Job Title   
Work Performed
Dates Employed — From
To
Hourly Rate/Salary — Starting Final
Reason for Leaving

3. Employer
 
Street Address

City State Zip Code

Supervisor
Job Title   
Work Performed
Dates Employed — From
To
Hourly Rate/Salary — Starting Final
Reason for Leaving

4. Employer
 
Street Address

City State Zip Code

Supervisor
Job Title   
Work Performed
Dates Employed — From
To
Hourly Rate/Salary — Starting Final
Reason for Leaving
Section 6
Additional Information
List professional, trade, business or civic activities and offices held.
 You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
 
Other Qualifications
 Summarize special job-related skills and qualifications acquired from employment or other experience.
 
Specialized Skills (Check Skills/Equipment Operated)

 
– –
Production/Mobile Machinery
 Other

 
State any additional information you feel may be helpful to us in considering your application.

Section 7
References
1. Reference

*Name

*Street Address

*City                            State

*Zip Code         

*Phone Number

2. Reference

Name

Street Address

City                            State

Zip Code         

Phone Number

3. Reference

Name

Street Address

City                            State

Zip Code         

Phone Number

Section 8
Applicant’s Statement
I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I authorize Primecare Medical Clinic to verify all of the information contained herein by contacting my previous employers and investigative agencies. I understand that an offer of employment is conditional on the satisfactory completion of background check, and drug screening tests.

This application for employment shall be considered active for a period of time not to exceed 45 days.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Primecare is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Primecare.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Primecare.

Application for employment, during the application process or any time during my employment if hired, may result in my application being withdrawn from further consideration, withdrawal of a conditional job offer or termination of employment if already employed when the falsification, misrepresentation, or omission occurs or is discovered.
Have you pled guilty to or been convicted of a crime, other than a minor traffic violation, in Arkansas or any other state or country?
Section 9
Request, authorization, consent and release for background information
I understand that in conjunction with my application for employment, Primecare Medical Clinic will use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications.

The outside agency will utilize various sources of information it deems appropriate including but not limited to employers, military records, school records, department of motor vehicles, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above named Primecare Medical Clinic. I unconditionally release and hold harmless Primecare Medical Clinic and any named or unnamed corporation, company, custodian of records or information from any and all liability resulting from furnishing information about me.

 

Other names used or known by:

Social Security Number:

Drivers' Licence Number:
Issuing State:

Please provide all residential addresses for the past 7 years:
Former Address 1
 

Street Address

City                         State

Zip Code         

Former Address 2
 

Street Address

City                         State

Zip Code         

Former Address 3
 

Street Address

City                         State

Zip Code         

Former Address 4
 

Street Address

City                        State

Zip Code         

Section 10
Form A – For Applicants and Current Employees Going Forward 

Please review the document entitled, “A Summary of Your Rights Under the Fair Credit Reporting Act” by clicking here. Please print this document for your records.

DISCLOSURE

In connection with either your application for employment or your continued employment with Primecare Medical Clinic, we may procure a “consumer report” (including an “investigative consumer report”) on you. A “consumer report” is any form of communication by a consumer reporting agency bearing on one’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living; it may include public record information (such as your driving record). An “investigative consumer report” is a special type of consumer report. If we intend to request such a report, you will be given a separate disclosure which describes such a report and your particular rights in that regard.

In the event that information from a “consumer report” is to be utilized in whole or in part in making an adverse decision with regard to your potential or continued employment, before making the adverse decision we will provide you with a copy of the consumer report provided to us, and a description of your rights under the federal Fair Credit Reporting Act. (The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. You have been given a summary of these rights together with this document.)

AUTHORIZATION

In order to be considered for employment with this company, by sumitting of this Application, I hereby authorize Primecare Medical Clinic or its representatives to obtain (a) consumer credit report(s). If I am hired, this authorization shall remain on file and in effect and shall serve as an ongoing authorization for Primecare Medical Clinic or its representatives to procure consumer reports at any time during my employment. I acknowledge receipt of a copy of a document entitled, “A Summary of Your Rights Under the Fair Credit Reporting Act.”

All information provided on this authorization will be used for the sole purpose of procuring a consumer report for employment purposes. Primecare Medical Clinic will not use the report obtained to violate any federal or state equal employment opportunity law or regulation.

 
     * I have read and understand the information in this section and was able to view a document entitled, “A Summary of Your Rights Under the Fair Credit Reporting Act.”
Section 11
READ CAREFULLY
I understand that if hired by Primecare Medical Clinic, employment and compensation can be terminated with or without cause or notice, at any time at the option of the company or the employee. This application is not a contract of employment between the applicant and the company. No words or actions of the company, including the employment offers or terms and conditions of employment are intended to establish an implied or expressed employment contract. Further, no representative of the company, other than the Director of Human Resources and one other company officer, has any authority to enter into any agreement for a specific period of time. Any such agreement entered into by those mentioned above will not be enforceable unless it is in writing.

I understand that a condition of employment is a post offer, drug screen and a background investigation.

I authorize the company and its representatives to contact prior employers and all others for the purpose of verification of the information I have supplied and release the same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested.

I certify the information given by me in connection with this application is true and accurate in all respects. Any omission or misrepresentation of facts may result in refusal to hire, or if hired, will be considered sufficient cause for termination.

Primecare Medical Clinic is an equal opportunity employer and does not lawfully discriminate on the basis of race, color, creed, religion, national origin, sex, age, disability or veteran status.

SUBMITTING THIS FORM IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE TERMS AND CONDITIONS.