New Hire Data

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Personal Information

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Addresses for Past 7 Years

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Direct Deposit Information

Emergency Contact Information (Second person is optional)

Background Check - Conviction or Deferred Adjudication

It 'Yes' please explain in detail giving dates and nature of offense, name and location of the court and disposition of the case. A conviction may not disqualify you but a false statement will. Note:some state agencies may require additional information related to convictions of misdemeanors
Have you been convicted of a felony or subject to deferred adjudication on a felony charge in the past 7 years? *

Tell Us About You

Attachments (Photos) = Driver's License, Social Security Card, Check with Bank Information




1. Employee Handbook Acknowledgement Form

Employee Handbook Acknowledgement Form

This is to state that I have reviewed the Employee Handbook and had an opportunity to ask Human Resources Dept. any questions regarding the policies and procedures outlined in it.  I agree to abide by the policies contained in the Handbook as a condition of my continued employment with the American Laser Med Spa.

I am aware that a copy of the Employee Handbook is available online in the document library at http://alcteam.weebly.com/document-library.html  OR http://alcteam.weebly.com/uploads/7/7/1/2/7712426/final_employee_handbook_-_may_08.pdf

  *

2. Wage Deduction Authorization Form

AUTHORIZATION TO MAKE DEDUCTIONS FROM WAGES

 

I understand and agree that my employer, American Laser Med Spa, may deduct money from my pay from time to time for reasons that fall into the following categories:

  1. The cost of repairing or replacing any Company supplies, materials, equipment, including, but not limited to goggles, spatulas, cameras, missing products, cash money missing from clinic cash box, or other property that I may damage (other than normal wear and tear), lose, fail to return, or take without appropriate authorization from the Company during my employment; this will also apply to any items that come up missing or stolen while I am on duty.
  2. My share of the premiums for the Company's group medical/dental plan.
  3. Any contributions I may make into a retirement or pension plan sponsored, controlled, or managed by the Company.
  4. Installment payments on loans or wage advances given to me by the Company. And if there is a balance remaining when I leave the Company, the balance of such loans or advances.
  5. If I receive an overpayment of wages for any reason, repayment of such overpayments to the Company.
  6. The cost to the Company of personal long-distance calls I may make on Company phones or on Company accounts, of personal faxes sent by me using Company equipment or Company accounts, or of non-work related access to the Internet or other computer networks by me using Company equipment or Company accounts.
  7. The reasonable cost or fair value, whichever is less, of meals, lodging, and other facilities furnished to me by the Company in connection with my employment.
  8. If I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from the Company before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered.
  9. Any other items appropriate for the company's situation.

I agree that American Laser Med Spa may deduct money from my pay under the above circumstances or if any of the above situations occur.

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3. Confidentiality Agreement Form

Confidentiality Agreement

I understand that any information that I may encounter concerning patients, practitioners and staff’s “protected information” will be treated as confidential.

“Protected information” means all health information past, present or future.

It also includes demographic information that identifies a person or gives reasonable basis to believe the information may identify that person.

I will not remove any documents or materials from the offices of American Laser Med Spa and at no time during or following my employment/contractual agreement will I use or disclose any confidential information.

I understand and agree to follow the terms and conditions of this confidentiality agreement.

I further understand that a breach of confidentiality will result in the immediate termination of my employment/contractual agreement with American Laser Center, and the possibility of legal action being taken against me.

 *

4. Non-Compete Clause Form

NON-COMPETE CLAUSE

By accepting this job offer, agree not to work directly for American Laser/Laser Physicians, PA’s direct competitors in a 50 mile radius for ONE YEAR after voluntarily leaving the job.  For example, I agree not to work at another clinic performing laser hair removal.

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5. CONSENT FOR BACKGROUND CHECK (CRIMINAL/CREDIT ETC) & DRUG TESTING

DISCLOSURE AND AUTHORIZATION FORM TO OBTAIN CONSUMER REPORTS (Criminal and Credit Check etc) & DRUG TESTING FOR EMPLOYMENT PURPOSES

Please Read Carefully Before Signing the Authorization
 
DISCLOSURE
 
In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, or discipline, Laser Physicians PA dba American Laser Med Spa (“the Company”) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc.
 
For explanation purposes:
 
a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminal history reports, or driving records; and
 
an “investigative consumer report” is a consumer report in which information on your character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with your prior employers, neighbors, friends, or associates, or with others who may have knowledge concerning any such items of information. In the event an investigative consumer report is requested about you, you are entitled to additional disclosures regarding the nature and scope of the investigation requested, as well as a written summary of your rights under the Fair Credit Reporting Act (“FCRA”).

Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA, upon written request.
 
CONSENT FOR BACKGROUND CHECK CONSUMER REPORTS (Criminal & Credit etc)
 
I have read and understand the foregoing Disclosure, and authorize the Company to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.
 
I authorize you to contact my current/previous employer for Employment and Reference Verifications. (This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.)
 
I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.
 
CONSENT FOR DRUG TESTING FOR PRE-EMPLOYMENT, RANDOM, OR REASONABLE SUSPICION AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT
 
I hereby CONSENT to allow Laser Physicians, PA dba American Laser Med Spa thru IntelliCorp or similar agency to take a specimen of my hair, urine, or blood and submit it for a pre-employment, random, or reasonable suspicion drug test screen.
 
I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to American Laser Med Spa. In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available.
 
I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against Laser Physicians, PA dba American Laser Med Spa, IntelliCorp, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and HOLD HARMLESS Laser Physicians, PA dba American Laser Med Spa, Intellicorp Inc, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.
 
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.
 
I certify that all of elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.
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Form W-4

Form I-9