Employment Application
ICCO, LLC Corporate name dba
Eugene Urgent Care
Thurston Urgent Care
Roseburg Urgent Care
Prime Care Partners
Junction City Medical Clinic
Atlas Physical Therapy
VISION:
ICCO, LLC is committed to providing fast, high quality, non-emergency
care and specializes in treating all non-life threatening injuries and
illnesses.
If you believe in our Core Values and can demonstrate them on a daily basis, this could be the ideal
employment opportunity for you.
CORE VALUES:
Demonstrates, through behavior, ICCO’s core values of Respect,
Compassion, Quality Healthcare, Humor, and Teamwork.
If you need help filling this out please call 541 852 5820
We are an EEO; all applicants for all available positions will be considered without regard to age, race, color, religious affiliation,
national origin, sex, sexual orientation, marital status, pregnancy, veteran status, disability and/or related medical conditions and any
other protected status governed by local, state, or federal law or ordinances.
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
Phone:
Date Available:
ZIP Code
Email
Active Licenses:
Desired Salary:$
Position Applied for:
YES
NO
Are you a citizen of the United States?
YES
NO
If no, are you authorized to work in the U.S.?
YES
NO
Have you ever worked for this company?
If yes, when?
YES
NO
Have you ever been convicted of a felony?
If yes, explain:
Applicant Questions
Why should we hire you?
_____________________________________________________________________________________________
Why do you want to work for ICCO, LLC?
_____________________________________________________________________________________________
Referral Source?
_____________________________________________________________________________________________
We staff employees from 7am-10pm. 7 days a week 365 days a year. Please list your available work hours.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
__________to __________
__________to __________
__________to __________
__________to __________
__________to __________
__________to __________
__________to __________
Prefer Urgent Care or Family Practice or Atlas Physical Therapy or All/Any (circle)?
Which locations are you available for work?
Circle all that apply.
Eugene Urgent Care
598 E. 13th Ave. Eugene, OR 97401 or
1800 Coburg Road Eugene, OR 97401 or
2710 Willamette St. Eugene, OR 97405
Thurston Urgent Care at 5781 Main St. Springfield, OR 97478
Pleasant Hill Medical Clinic and Urgent Care 35859 Hwy. 58 Pleasant Hill, OR 97455
Atlas Physical Therapy all above locations
Prime Care Partners 1800 Coburg Road Eugene, OR 97401 or
2710 Willamette St. Eugene, OR 97405
Junction City Medical Clinic/Urgent Care 355 W. 3rd Junction City, OR 97448
Roseburg Urgent Care 1740 NW Goetz St. Roseburg, OR 97471
Previous Employment
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary:$
Responsibilities:
From:
To:
Reason for Leaving:
YES
NO
May we contact your previous supervisor for a reference?
Name/Phone ____________________
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary: $
Responsibilities:
From:
To:
Reason for Leaving:
YES
NO
May we contact your previous supervisor for a reference?
Name/Phone ____________________
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Responsibilities:
From:
To:
Reason for Leaving:
Ending Salary: $
YES
NO
May we contact your previous supervisor for a reference?
Name/Phone ____________________
Previous Employment Continued
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:$
Ending Salary: $
Responsibilities:
From:
To:
Reason for Leaving:
YES
May we contact your previous supervisor for a reference?
NO
Name/Phone ____________________
Other Skills and Qualifications:
Summarize any job-related training, skills, licenses, certificates, and/or other
qualifications:
Educational History:
List school name and location, years completed, course of study, and any
degrees earned:
High school or GED:
College:
Technical Training:
Other:
Military Service:
Branch of service__________________________________________
Experience and skills gained_________________________________
Thank you for applying.
You may mail applications to ICCO, LLC attention Human Resources PO BOX 824 Eugene, OR 97401 or drop
off at the front desk to any of the below locations.
Eugene Urgent Care
598 E. 13th Ave. Eugene, OR 97401 or
1800 Coburg Road Eugene, OR 97401 or
2710 Willamette St. Eugene, OR 97405
Thurston Urgent Care at 5781 Main St. Springfield, OR 97478
Pleasant Hill Medical Clinic and Urgent Care 35859 Hwy. 58 Pleasant Hill, OR 97455
Atlas Physical Therapy all above locations
Prime Care Partners 1800 Coburg Road Eugene, OR 97401 or
2710 Willamette St. Eugene, OR 97405
Junction City Medical Clinic/Urgent Care 355 W. 3rd Junction City, OR 97448
Roseburg Urgent Care 1740 NW Goetz St. Roseburg, OR 97471
Below list any names by which you have been known which may be necessary for us to confirm your work and
educational record. For example change of name, use of an assumed name, nicknames. Etc.
______________________________________________________________________________________
I understand and agree that driving is a requirement of the job for which I am applying and my employment is contingent on
possessing a valid driver’s license for the state which I am employed and liability insurance in an amount equal to the minimum is
required.
I understand that the company may now have or may establish a drug free/smoke free/ or drug/smoke and or alcohol testing program
consistent with applicable federal/state/and local law. If ICCO, LLC has such a program and I am offered a conditional offer of
employment, I understand that if a pre-employment (post offer) drug/and or alcohol test is positive, the employment offer may be
withdrawn. I agree to work under the conditions requiring a drug free workplace, consistent to federal/state/local law which means I
may be subject to urinalysis and or blood screening or other medically recognized tests designed to detect the presence of alcohol or
illegal or controlled drugs. If employed I understand that the taking of such tests is a condition of continual employment and I agree to
undergo tests that conform to company policy and federal/state/local laws.
If employed I understand and agree that ICCO, LLC may to the extent permitted by federal/state/local law may exercise its right
without prior warning or notice, to conduct investigations of property including my files, my desk, lockers and computers and in some
circumstances my personal property.
I also understand and agree that as a condition of employment I will be required to sign confidentiality, code of conduct and employee
handbook receipt of acknowledgment of expected behaviors.
ICCO is an At-will employer as allowed by state law. This means that regardless of any provisions in this application, if hired the
company or I may terminate the employment relationship at any time, for any reason, with our without cause or notice. No officer,
employee or representative of the company is authorized to enter into an agreement, express or implied with me or any applicant for
employment for a specified period of time, unless such agreement is in a written contract and signed by the CEO of the company.
I certify that all information on this application, my resume and all supporting documents I present are complete and accurate to the
best of my knowledge. I understand that any falsification misrepresentation, or omission of any information may result in my
disqualification from consideration for employment or, if employed disciplinary action up to immediate dismissal.
Applicant’s Signature and Date
__________________________________________________________________