0467 - Michigan Road Animal Hospital - Employment Application Form

We appreciate your interest. We are an equal employment opportunity employer. Our policy is not to discriminate against any applicant or employee based on race, color, sex, religion, national origin, age (40 and over), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. We also prohibit harassment of applicants or employees based on any of these protected categories. It is also our policy to comply with all applicable federal, state and local laws respecting consideration of unemployment status in making hiring decisions.

Note to Applicants: Smoking is prohibited in all indoor areas unless designated smoking areas have been established by a particular location in accordance with applicable state and local law.

Note to Rhode Island Applicants: We are subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island, and are
therefore covered by the state’s workers’ compensation law.
Position for Which You Are Applying*
Please select your credentials (if applicable)
If other, please specify
CONTACT INFORMATION
Full Name*

First NameLast Name
Have you ever used any other name(s) which is (are) necessary for us to know in order for us to verify your employment or educational record?*

YesNo
Please provide the other name(s).*
Email*
example@example.com
Mobile Phone*
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Work Phone*
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Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
UPLOAD YOUR RESUME AND COVER LETTER

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EMPLOYMENT HISTORY

Please specify your complete full-time and part-time employment history, including self-employment. You may include any verified work performed on a volunteer basis. Begin with your most recent employer.
Company Name*
Address*
Company Phone Number*
Please enter a valid phone number.
Name, Title, and Phone Number of Supervisor*
Your Job Title*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Responsibilities*
Reason for Leaving*
May we contact your current employer?*

YesNo
Add additional employment

Yes
EMPLOYMENT 2
Company Name*
Address*
Company Phone Number*
Please enter a valid phone number.
Name, Title, and Phone Number of Supervisor*
Your Job Title*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Responsibilities*
Reason for Leaving*
May we contact your current employer?*

YesNo
Add additional employment

Yes
EMPLOYMENT 3
Company Name*
Address*
Company Phone Number*
Please enter a valid phone number.
Name, Title, and Phone Number of Supervisor*
Your Job Title*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Responsibilities*
Reason for Leaving*
May we contact your current employer?*

YesNo
EDUCATION

Please add the following if applicable: Business/Trade/Technical School, High School, College, and Graduate School.
Which form of schooling is listed below?*

CollegeGraduate SchoolHigh SchoolBusiness/Trade/Technical School
School Name*
Location*
Degree Earned*
Major*
Number of Years Completed
Start Date*

MonthDayYear
End Date*

MonthDayYear
Additional Details
Add Additional Education

Yes
Education 2
Which form of schooling is listed below?*

CollegeGraduate SchoolHigh SchoolBusiness/Trade/Technical School
School Name*
Location*
Degree Earned*
Major*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Additional Details
Add Additional Education

Yes
Education 3
Which form of schooling is listed below?*

CollegeGraduate SchoolHigh SchoolBusiness/Trade/Technical School
School Name*
Location*
Degree Earned*
Major*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Additional Details
LICENSES & CERTIFICATIONS
Please list all licenses and certifications applicable to the position for which you are applying.
SKILLS & QUALIFICATIONS
Please list any other job-related qualifications such as special skills, abilities, or honors that should be considered.
REFERRAL SOURCE
How did you hear about this opportunity?*
Have you worked for this company previously*

YesNo
If you have previously worked for this company, then please provide additional details:
Do you know anyone who works for our company?*

YesNo
If you do know anyone who works for our company, please provide their name(s).
QUESTIONS
When are you available to start?*

MonthDayYear
If you have scheduling restrictions, please specify
Are you available to work overtime as needed?*

YesNo
Are you available to work weekdays? weekends?*
Are you at least 18 years of age?*

YesNo
Are you legally authorized to work in the United States?*

YesNo
If hired, are you able to provide proof of eligibility to work?*

YesNo
Will you now or in the future require sponsorship for employment visa status (e.g. H-1B status)?*

YesNo
Are you willing to submit to a drug test and background check?*

YesNo
Are you up to date on your tetanus shot?*

YesNo
If not, can you get a tetanus shot before hire?*

YesNo
Do you have reliable transportation?*

YesNo
If applying for a position that will include driving:

If hired, you may be required to provide evidence of insurance or insurability
If hired can you provide a valid driver's license?

YesNo
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?*

YesNo
Have you ever been terminated from employment or asked to resign by an employer?*

YesNo
If yes, please provide company names and details regarding your termination or resignation.*
What is your salary expectation?*
PROFESSIONAL REFERENCES

Individuals not related to you. Business references preferred.
Reference 1 Name*

First NameLast Name
Reference 1 Phone Number*
Please enter a valid phone number.
Reference 1 Years Known and Capacity*
Reference 1 Occupation*
Reference 2 Name*

First NameLast Name
Reference 2 Phone Number*
Please enter a valid phone number.
Reference 2 Years Known and Capacity*
Reference 2 Occupation*
Reference 3 Name*

First NameLast Name
Reference 3 Phone Number*
Please enter a valid phone number.
Reference 3 Years Known and Capacity*
Reference 3 Occupation*
Applicant's Statement and Acknowledgment

THIS APPLICATION IS NOT COMPLETE UNTIL IT IS FULLY COMPLETED, SIGNED, ANDALL STATEMENTS BELOW HAVE BEEN READ AND INITIALED.
Initial*
I certify that all of the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire or, if hired, may result in my dismissal at any time regardless of when the false answer or omissions are discovered.
Initial*
I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Company, I will be an at-will employee, meaning that either the Company or I may end the employment relationship at any time with or without cause or notice. I understand that only authorized representatives with explicit authority to enter into agreements, and no manager, supervisor, or other non-authorized representative of
the Company, has authority to enter into any agreement for employment for any specified period of time, or to
make any agreement contrary to the at-will employment relationship, and with respect to any agreement entered
into by the explicitly authorized representative, any such agreements must be in writing and signed by the
explicitly authorized representative and by me or my authorized representative. You may contact human resources to inquire as to who the explicitly authorized representative is.
Initial*
I further understand and agree that, except for my at-will employment status, if hired, my wages, hours, working
conditions, job assignment(s), and compensation rate(s) will be subject to change by the Company.
Initial*
I understand that if I am offered employment, I may be required to sign a non-solicitation and non-disclosure
agreement, as a condition of the employment.
Initial*
I understand that the Company may share the information contained in this application with other Company
employees for employment and administrative purposes and hereby consent to such transfer.
Initial*
I hereby authorize, to the extent allowed by applicable federal state and local laws, the Company to conduct its
own investigation of my references, employment history and education and, further, authorize the references and prior employers I have listed to disclose to the Company information related to my employment history and
qualifications for the position for which I am applying, without giving me prior notice of such disclosure.
Initial*
I understand and expressly agree that if employed by the Company, storage areas provided for me (locker, desk,
etc.) are open to investigation by the Company without prior notice to me.
Initial*
I agree to undergo a pre-employment physical examination consistent with federal and state law.
Initial*
I agree to undergo a pre-employment physical examination consistent with federal and state law.
Initial*
I agree to submit to legally permissible drug testing upon an offer of employment from the Company and prior to starting work. I agree that any offer of employment is contingent upon my receiving a negative test result.
Initial*
Delaware, Massachusetts, New York, Oregon, Puerto Rico and California Applicants: I understand that the
Company may not ask or require applicants to disclose past salary, wages or other compensation.
Initial*
Massachusetts Applicants: I understand that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
Initial*
Maryland Applicants: I UNDERSTAND THAT UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT ANY INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH OR SIMILAR
TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Michigan Road Animal Hospital to hire me. If I am hired, I understand that either Michigan Road Animal Hospital or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Michigan Road Animal Hospital has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to Michigan Road Animal Hospital true and complete information on this application. No requested information has been concealed. I authorize Michigan Road Animal Hospital to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.
DISCLAIMER
ARBITRATION AGREEMENT

Please read the following Arbitration Agreement carefully, then acknowledge that you have read and agreed to it by providing the information requested at the bottom of the page.
ARBITRATION AGREEMENT. The Company (which includes jointly and separately the National Veterinary Associates, Inc. (“NVA”) and any parents, subsidiaries, affiliates and/or related entities) and I mutually understand, contract and agree, through this
“Arbitration Agreement,” that any and all claims and/or disputes, past, present or future, between me and the Company, arising out of or related to my application for employment (including without limitation denial of this application) shall be decided by an arbitrator
through arbitration and not by way of court or jury trial. The Arbitrator shall be selected by mutual agreement of the Company and me. Unless the Company and I mutually agree otherwise, the Arbitrator shall be an attorney licensed to practice in the location
where the arbitration proceeding will be conducted or a retired federal or state judicial officer who presided in the jurisdiction where the arbitration will be conducted. If for any reason the parties cannot agree to an Arbitrator, either party may apply to a court of
competent jurisdiction with authority over the location where the arbitration will be conducted for appointment of a neutral Arbitrator. The court shall then appoint an arbitrator, who shall act under this Agreement with the same force and effect as if the parties had selected the arbitrator by mutual agreement. The location of the arbitration proceeding shall be no more than 45 miles from and in
the same state where I applied and/or last worked for the Company, unless each party to the arbitration agrees in writing otherwise. The Federal Arbitration Act (9 U.S.C. § 1 et seq.) shall apply to this Arbitration Agreement.

Except for claims that are excluded below, this Arbitration Agreement applies to any and all covered claims and/or disputes that the
Company may have against me or that I may have against: (1) the Company, (2) its or their officers, directors, employees, or agents
in their capacity as such or otherwise, and (3) all successors and assigns of any of them. Disputes subject to this Arbitration Agreement include without limitation, to disputes with any entity or individual arising out of or related to the application for
employment (including denial of that application), background checks, privacy, contracts, trade secrets, unfair competition, compensation, classification, minimum wage, seating, expense reimbursement, overtime, breaks and rest periods, retaliation,
discrimination, or harassment and claims arising under the Fair Credit Reporting Act, Defend Trade Secrets Act, Title VII of the Civil Rights Act of 1964, 42 U.S.C. §1981, the Rehabilitation Act, the Civil Rights Acts of 1866 and 1871, the Civil Rights Act of 1991, the
Pregnancy Discrimination Act, Equal Pay Act, Americans With Disabilities Act, Age Discrimination in Employment Act, Family Medical Leave Act, Fair Labor Standards Act, Employee Retirement Income Security Act (except for claims for employee benefits
under any benefit plan sponsored by the Company and (a) covered by the Employee Retirement Income Security Act of 1974 or (b) funded by insurance), Affordable Care Act, Genetic Information Non-Discrimination Act, Uniformed Services Employment and
Reemployment Rights Act, Worker Adjustment and Retraining Notification Act, Older Workers Benefits Protection Act of 1990, Occupational Safety and Health Act, Consolidated Omnibus Budget Reconciliation Act of 1985, False Claims Act, state or local
statutes or regulations addressing the same or similar subject matters, and all other federal, state or local statutory and legal claims (including without limitation torts) arising out of or relating to my application for employment or denial of that application. Further,
covered claims and/or disputes include any claim or controversy regarding this Arbitration Agreement or any portion of the Arbitration Agreement or its interpretation, enforceability, applicability, unconscionability, arbitrability or formation, or whether the Arbitration Agreement or any portion of it is void or voidable, with the exception noted in the Class Action Waiver below.

The following claims and/or disputes are not covered under this Arbitration Agreement: (i) Workers’ Compensation benefit claims; (ii)
state unemployment or disability insurance compensation claims; (iii) claims for benefits under employee benefit plans covered by ERISA that contain an appeal procedure or other exclusive and/or binding dispute resolution procedure in the respective plan; (iv)
claims under the National Labor Relations Act within the jurisdiction of the National Labor Relations Board; (v) claims that the DoddFrank Wall Street Reform and Consumer Protection Act (Public Law 111-203) or as provided by another Act of Congress are not
arbitrable under this Agreement. Regardless of any other terms of this Arbitration Agreement, a claim may be brought before and remedies awarded by an administrative agency if, and only if, applicable law permits the agency to adjudicate the claim
notwithstanding the existence of an agreement to arbitrate. Such administrative claims include without limitation claims or charges brought before the Equal Employment Opportunity Commission (www.eeoc.gov), the U.S. Department of Labor (www.dol.gov), the National Labor Relations Board (www.nlrb.gov), the Office of Federal Contract Compliance Programs (www.dol.gov/esa/ofccp) and law enforcement authorities. I understand the Company will not retaliate against me for filing such a charge. Nothing in this Agreement prevents the investigation by a government agency of any report, claim or charge otherwise covered by this Agreement. This Agreement also does not prevent federal administrative agencies from adjudicating claims and awarding remedies based on those claims, even if the claims would otherwise be covered by this Agreement. Nothing in this Agreement prevents or excuses a party from satisfying any conditions precedent and/or exhausting administrative remedies under applicable law before bringing a
claim in arbitration. I understand and acknowledge that the Company will not retaliate against me for filing a claim with an administrative agency or for exercising rights (individually or in concert with others) under Section 7 of the National Labor Relations
Act.

Class Action Waiver: Private Attorney General representative actions under the California Labor Code are not covered by this Agreement, not arbitrable, and may be maintained in a court of law, but individual claims I bring for recovery of unpaid wages shall be subject to this Agreement. I understand this Agreement affects my ability to participate in class or collective actions. Both the Company and I agree to bring any dispute in arbitration on an individual basis only, and not on a class or collective basis. There will be no right or authority for any dispute to be brought, heard or arbitrated as a class or collective action, or as a member in any such class or collective proceeding (“Class Action Waiver”). Notwithstanding any other provision of this Agreement, disputes regarding the validity, enforceability or breach of the Class Action Waiver may be resolved only by a civil court of competent jurisdiction and not by an arbitrator. In any case in which (1) the dispute is filed as a class or collective action and (2) there is a final judicial determination that all or part of the Class Action Waiver unenforceable, the class and/or collective action to that extent must be litigated in a civil court of competent jurisdiction, but the portion of the Class Action Waiver that is enforceable shall be enforced in arbitration.

I understand and acknowledge and the Company agrees that I will not be retaliated against, disciplined or threatened with discipline as a result of filing of or participation in a class or collective action in any forum. However, I understand the Company may lawfully
seek enforcement of this Agreement and the Class Action Waiver under the Federal Arbitration Act and seek dismissal of such class or collective actions or claims. Notwithstanding any other clause contained in this Agreement, any claim in court or arbitration that all or part of the Class Action Waiver is invalid, unenforceable, unconscionable, void or voidable may be determined only by a court and
not by an arbitrator.

The Class Action Waiver shall be severable in any case in which the dispute is filed as an individual action and severance is necessary to ensure that the individual action proceeds in arbitration.
DO NOT SIGN UNTIL YOU HAVE CAREFULLY READ THE ABOVE ARBITRATION AGREEMENT. BY SIGNING BELOW, YOU ARE AGREEING THAT YOU HAVE CAREFULLY READ THIS ARBITRATION AGREEMENT AND ARE YOU ARE GIVING UP YOUR RIGHT TO A COURT OR JURY TRIAL ON COVERED CLAIMS, AND THAT PURSUANT TO THE TERMS OF THIS ARBITRATION AGREEMENT, YOU AND THE COMPANY ARE AGREEING TO ARBITRATE DISPUTES COVERED BY THIS
ARBITRATON AGREEMENT. YOU ARE FREE TO MAKE A COPY OF THE SIGNED APPLICATION AND THIS ARBITRATION AGREEMENT PRIOR TO SUBMISSION OF THE SAME. YOU CAN ALSO REQUEST A COPY OF THE SIGNED APPLICATION
AND ARBITRATION AGREEMENT FROM HUMAN RESOURCES.
My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains all the understandings between the Company and me concerning the topics addressed herein, and supersedes any prior inconsistent understandings between the Company and me on such issues.
Printed Name for E-Signature*

First NameLast Name
Date*

MonthDayYear
This application will only be considered for 30 days. If you have not been hired within 30 days of submitting this application and you wish to continue to be considered for employment, you must complete another application.
Are You A Robot?*
Should be Empty:

CONTACT INFORMATION

UPLOAD YOUR RESUME AND COVER LETTER

EMPLOYMENT HISTORY

EMPLOYMENT 2

EMPLOYMENT 3

EDUCATION

Education 2

Education 3

LICENSES & CERTIFICATIONS

SKILLS & QUALIFICATIONS

REFERRAL SOURCE

QUESTIONS

PROFESSIONAL REFERENCES

Applicant's Statement and Acknowledgment

DISCLAIMER

ARBITRATION AGREEMENT