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Javier Rios, MD

A Medical Professional Corporation

9939 Magnolia Ave Riverside, CA 92503
(951) 687-802

Employment Application

WE APPRECIATE YOUR INTEREST IN OUR ORGANIZATION. AS AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER, WE DO NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGION, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, AGE, DISABILITY, VETERAN’S STATUS, MARITAL STATUS, NATIONAL ORIGIN, ANCESTRY, PREGNANCY, CITIZENSHIP, MEDICAL CONDITION, OR ANY OTHER CLASSIFICATION PROTECTED BY LAW. A CLEAR UNDERSTANDING OF YOUR BACKGROUND AND WORK HISTORY WILL HELP US EVALUATE YOUR QUALIFICATIONS FOR EMPLOYMENT.

PERSONAL


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LEGAL WORK STATUS & OTHER NAMES

*ARE YOU LESS THAN
18 YEARS OF AGE?

YesNo

*IF HIRED, CAN YOU PROVIDE
PROOF OF IDENTITY AND LEGAL
AUTHORIZATION TO WORK IN
THE U.S.?

YesNo

OTHER NAME(S) UNDER WHICH YOU HAVE BEEN PREVIOUSLY EMPLOYED AND/OR ATTENDED SCHOOL:

RELATION WITH US

*HAVE YOU EVER APPLIED TO THIS ORGANIZATION BEFORE?

YesNo

IF YES, GIVE DATE(S) AND POSITION(S) APPLIED FOR:

*HAVE YOU EVER BEEN EMPLOYED BY OUR ORGANIZATION BEFORE?

YesNo

IF YES, GIVE DATE OF EMPLOYMENT:

*ARE YOU WILLING TO WORK OVERTIME, OR A FLEXIBLE WORK SCHEDULE?

YesNo

*ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR
WHICH YOU APPLYING WITH OR WITHOUT A REASONABLE ACCOMMODATION?

YesNo

WHAT IS YOUR SALARY EXPECTATIONS?

INCASE OF EMERGANCY, NOTIFY:

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EMPLOYMENT INTERESTS

POSITION DESIRED OR AREA OF INTEREST:

SECOND CHOICE:

*DATE AVAILABLE:

SALARY/WAGE EXPECTED:

*TYPE OF EMPLOYMENT YOU ARE SEEKING?

FULL-TIMEPART-TIMETEMPORARYSUMMER

*SHIFTS YOU CAN WORK?

DAYSWINGNIGHT

*HOW WERE YOU REFERRED TO OUR ORGANIZATION?

ADVERTISEMENTOTHER COMPANYUNEMPLOYMENT AGENCYSELFEMPLOYEESCHOOLSTAFFING SERVICEOTHER

NAME OF REFERRAL SOURCE OR IF SELF, PLEASE EXPLAIN.

EDUCATION/PROFESSIONAL SKILLS

HIGH SCHOOL

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COLLEGE

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OTHER

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What was your major?

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YESNO

PRESENT COMMUNITY AND/OR PROFESSIONAL AFFILIATIONS/OFFICES HELD (The Company is only seeking information relevant for purposes of the applicant’s qualifications for the position(s) desired.)

YOU MAY EXCLUDE AFFILIATIONS WHICH MAY INDICATE RACE, COLOR, ANCESTRY, SEX, SEXUAL ORIENTATION, GENDER IDENTITY, MARITAL STATUS, PREGNANCY, CITIZENSHIP, MEDICAL CONDITION, DISABILITY, VETERAN’S STATUS, RELIGION, AGE, NATIONAL ORIGIN OR ANY OTHER CLASSIFICATION PROTECTED BY LAW.


EMPLOYMENT HISTORY

GIVE EMPLOYMENT RECORD AS COMPLETELY AS POSSIBLE, LISTING CURRENT OR MOST RECENT EMPLOYER FIRST. SHOW UNEMPLOYED OR SELF-EMPLOYED PERIODS AND INDICATE DATES AND COMMENT ON EACH PERIOD. INCLUDE PART TIME OR SUMMER WORK. YOU MAY USE THE SPACE PROVIDED BELOW OR THE LAST PAGE FOR ADDITIONAL INFORMATION.


Most Current Job

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DATES EMPLOYED (Approximately)

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*MAY WE CONTACT THIS EMPLOYER/SUPERVISOR?

YesNo

*DESCRIPTION OF DUTIES

*REASON FOR LEAVING

Second Most Current Job

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*DATES EMPLOYED (Approximately)

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*MAY WE CONTACT THIS EMPLOYER/SUPERVISOR?

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*DESCRIPTION OF DUTIES

*REASON FOR LEAVING

Third Most Current Job

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*MAY WE CONTACT THIS EMPLOYER/SUPERVISOR?

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*DESCRIPTION OF DUTIES

*REASON FOR LEAVING

*HAVE YOU EVER BEEN TERMINATED OR ASKED TO RESIGN FROM ANY EMPLOYMENT?

YesNo

IF YES, EXPLAIN

ADDITIONAL COMMENTS ON QUALIFICATIONS (Employement History, Professional Skills and/or education):

REFERENCES

LIST FIVE (5) PEOPLE WE MAY CONTACT WHO ARE QUALIFIED TO EVALUATE YOUR CAPABILITIES (Do not include relatives.)


Referral 1

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Referral 2

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Referral 3

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Referral 4

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Referral 5

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to read Acknowledgement & Agreement

Please be advised that the Company maintains a drug-free workplace. Violation of the Company’s drug and alcohol policy by an employee may lead to discipline up to and including discharge of employment. Applicants for regular employment with the Company who have received conditional offers of employment may be required to undergo a blood, urine or other laboratory test to screen for the presence of alcohol, illegal drugs, and/or controlled substances in their system. The test will be conducted at the Company’s expense at a licensed facility designated by the Company. Prior to testing, each prospective employee must consent in writing to such a test, and must authorize the release of the test results to The Company. If the test results are positive (i.e., the results confirm the presence of illegal drugs or controlled substances, or an unacceptable level of alcohol in the system), or if the test indicates that a false specimen was substituted or the specimen was tampered with or adulterated so as to render the test results invalid, the applicant will not be permitted to commence work for the Company. The Company does not discriminate against any applicant or employee on the basis of disability or medical condition, and the lawful use of prescribed medication will not be used as the basis for any adverse employment action. You may be required to provide information to the laboratory concerning lawfully prescribed drugs that you are taking, so that those drugs will not be considered a positive drug test result for employment or disciplinary purposes. Any information provided by you or your health care provider concerning your use of lawfully prescribed medications will be treated as confidential medical information. Any acceptance of employment will be predicated upon the truthfulness of the statements contained in this application and made during the pre-employment process. Any misrepresentation, falsification or omission of information may result in denial of employment or, if hired, may result in termination. Applicants for regular employment with the Company who have received conditional offers of employment may be required to consent to a consumer report, consumer credit report, and/or investigative consumer report as a condition of employment. I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED MY EMPLOYMENT IS FOR AN UNSPECIFIED TERM AND IS AT-WILL. ACCORDINGLY, EITHER I OR THE COMPANY CAN TERMINATE THE EMPLOYMENT RELATIONSHIP AT WILL AT ANY TIME, WITH OR WITHOUT CAUSE OR PRIOR NOTICE. THIS AT-WILL ASPECT OF MY EMPLOYMENT, WHICH INCLUDES THE RIGHT OF THE COMPANY TO DEMOTE, TRANSFER OR DISCIPLINE ME, OR CHANGE MY COMPENSATION, WITH OR WITHOUT CAUSE OR PRIOR NOTICE, CANNOT BE CHANGED, WAIVED OR MODIFIED, EXCEPT IN AN INDIVIDUALIZED WRITTEN EMPLOYMENT AGREEMENT, SIGNED BY BOTH ME AND THE COMPANY’S PRESIDENT. Except as required in the performance of my duties, I understand and agree that I will not at any time during or after my employment use, disclose or disseminate any trade secret, confidential or other proprietary or generally undisclosed nature relating to the Company, or its products, customers, employees, plans or procedures. I agree to deliver to the Company any and all copies of confidential information, or other Company property, upon termination of the employment relationship or at any time upon the Company’s request. I also agree not to solicit employees of the Company either during or for one year after employment to leave the Company and commence with another employer. I further expressly acknowledge and agree that, to the fullest extent allowed by law, any controversy, claim or dispute between me and the Company (and/or any of its owners, directors, officers, employees, affiliates, or agents) relating to or arising out of my employment or the cessation of that employment will be submitted to final and binding arbitration in the county in which I worked for determination in accordance with the American Arbitration Association’s ("AAA") National Rules for the Resolution of Employment Disputes, as the exclusive remedy for such controversy, claim or dispute. In any such arbitration, the parties may conduct discovery to the same extent as would be permitted in a court of law. The arbitrator shall issue a reasoned, written decision, and shall have full authority to award all remedies that would be available in court. The Company shall pay all arbitrator’s fees and any AAA administrative expenses. Any judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. Possible disputes covered by the above include (but are not limited to) unpaid wages, breach of contract, torts, violation of public policy, discrimination, harassment, or any other employment-related claims under laws including but not limited to, Title VII of the Civil Rights Act of 1964, the Americans With Disabilities Act, the Age Discrimination in Employment Act, applicable State laws, and any other statutes or laws relating to an employee's relationship with his/her employer, regardless of whether such disputes is initiated by me or the Company. This bi-lateral arbitration agreement fully applies to any and all claims that the Company may have against me, including but not limited to, claims for misappropriation of Company property, disclosures of proprietary information or trade secrets, interference with contract, trade libel, gross negligence, or any other claim for alleged wrongful conduct or breach of the duty of loyalty. However, claims for workers’ compensation benefits, unemployment insurance and those arising under the National Labor Relations Act (or other claims where mandatory arbitration is prohibited by law) are not covered by this arbitration agreement, and such claims may be presented by either the Company or me to the appropriate court or government agency. BY AGREEING TO THIS BINDING MUTUAL ARBITRATION PROVISION, BOTH THE COMPANY AND I GIVE UP ALL RIGHTS TO A TRIAL BY JURY. This bi-lateral arbitration agreement is to be construed as broadly as is permissible under applicable law.

to read Background Check Authorization

I understand that I have the right to make a request to the consumer reporting agency: Background Source International, PO Box 2760, Coeur D’ Alene, ID. 83816, 866-769-7281. Upon proper identification, to obtain copies of any reports furnished to “Clinica Medica Familiar” by Background Source International and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information, and Background Source International, on “Clinica Medica Familiar” behalf, will provide a complete and accurate disclosure of the nature and scope of the investigation covered by an investigative consumer report(s). Background Source International will also disclose the recipients of any such reports on me which Background Source International has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I hereby consent to “Clinica Medica Familiar” obtaining the above information from Background Source International. I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the agency. I may view the Background Source International’s privacy policy at their website: Background Source I understand that if the “Clinica Medica Familiar” is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report “Clinica Medica Familiar” receives on me at the time the report is provided to the “Clinica Medica Familiar”. By checking the following box, I request a copy of all such reports be sent to me. Check Here I want a Copy. As a California applicant, I understand that I have the right under Section 1786.22 of the California Civil Code to contact the Agency during reasonable hours (9:00 am to 5:00 pm (PTZ) Monday through Friday) to obtain all information in Background Source International’s file for my review. I may obtain such information as follows: 1) In person at the Background Source International which address is listed above. I can have someone accompany me to Background Source International’s offices. Background Source International may require this third party to present reasonable identification. I may be required at the time of such visit to sign an authorization for Background Source International to disclose or to discuss Background Source International with this third party. 2) By certified mail, if I have previously provided identification in a written request that my file be sent to me or to a third party identified by me; 3) By telephone, if I have previously provided proper identification in writing to Background Source International and 4) Background Source has trained personnel to explain any information in my file to me and if the file contains any information that is coded, such will be explained to me.

In connection with my application for employment, I direct the following regarding my current employer: May we contact your Current Employer?

YesNo

For Identification Purposes: