City *
State *
Are you authorized to work in the US? *
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Yes
No
Do you now or will you in the future require immigration sponsorship? *
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Yes
No
Have you ever been employed by Sollis Health, previously Priority Private Care? *
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Yes
No
Do you or have you had any civil malpractice suits filed against you? If yes, please explain further. *
1. Please, input Yes or No below
2. If yes, please explain further
Has any of your professional or occupational registration, licensure or certification applicable to this position, been surrendered, suspended, revoked, terminated, or expired? If yes, please explain further. *
1. Please, input Yes or No below
2. If yes, please explain further
Do you or any immediate family member(s) have any current personal relationships, current employment relationships, and/or current or past consulting arrangements or agreements, with any entity or individual that could be considered a potential competitor of Sollis Health or its affiliate(s)? If yes, please explain further. If no, put N/A *
Do you or any immediate family member(s) have any financial interests, including ownership and/or investment interests (e.g., stock, equity, etc.) in any entity that could be considered a potential competitor of Sollis Health or its affiliate(s)? If yes, please explain further. If no, put N/A *
By checking yes, you consent to receiving text messages from us at the cell phone number you provided regarding your application or open positions for which you may be eligible. We will not text you for marketing or other commercial purposes, but only in connection with your application or candidacy for employment. Depending on your cell phone carrier and plan, standard messaging charges may apply. You can always opt out of receiving future text messages by texting back STOP. *
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Yes
No
I certify that the information filled out above is true and accurate to the best of my knowledge. Please sign your name. *
Applicant's Statement and Agreement *
Please read the following statement carefully. By providing your electronic signature, you acknowledge that you have read and understand this statement. DO NOT SIGN UNTIL YOU HAVE READ THE BELOW STATEMENT IN FULL.
Equal Employment Opportunity Statement
Sollis Health (the “Company”) is proud to be an equal opportunity employer, and is committed to providing equal employment opportunities to all employees and applicants without regard to race; color; national origin; religion; age; sex (including pregnancy, childbirth, breastfeeding, and related medical conditions); gender identity or expression; affectional or sexual orientation; actual and/or perceived disability (mental and physical); atypical hereditary cellular or blood trait or genetic information (including family medical history); uniform service member and veteran status; participation in legally protected conduct or making a complaint relating to unlawful conduct; and any other characteristic protected by applicable federal, state, or local law.
Applicant’s Statement
I affirm that all the information that I have provided on this application, or any other documents completed in connection with my prospective employment, and in any interview(s), is true and accurate. I affirm that I have withheld nothing that would, if disclosed, affect this application for employment unfavorably. I understand that if I am employed and any information provided to the Company is found to be false or incomplete in any respect, my employment may be terminated immediately.
I agree that, if hired, my employment shall not be for any specific duration and either the Company or I may terminate my employment relationship at any time, with or without cause and/or with or without prior notice. This express at-will acknowledgement supersedes any and all prior representations or understandings, whether written or oral, express or implied, between the Company and me. My employment-at-will status, if I am hired, may only be changed in a written and signed document.
I agree to receive electronic communications, updates, and notifications from the Company regarding my application for employment, candidate status, or additional available positions within the Company for which I may be qualified, via the contact information I have provided in conjunction with my electronic job application submission. I further agree to accept any potential carrier costs or fees which may be associated with such communications, including, but not limited to, e-mail, phone, or SMS text message.
Agreement to Submit Claims to Binding Arbitration
By typing my electronic signature below, I agree to utilize binding arbitration pursuant to the Federal Arbitration Act as the sole and exclusive means to resolve all Covered Disputes (as defined in paragraph 9) that may arise from, relate to, or have any relationship or connection whatsoever to my application for employment with, employment with or termination from employment by, or other association with the Company, whether based in tort, contract, statutory, or common law, and whether based in law or equity, or that would otherwise be resolved in a court of law or before a forum other than arbitration, with the exception agrees to submit to arbitration any claims it may have against me that it otherwise would be allowed or required to submit to any court or government dispute forum. I FURTHER UNDERSTAND THAT BY AGREEING TO SUBMIT COVERED DISPUTES TO ARBITRATION, BOTH THE COMPANY AND I GIVE UP OUR RIGHTS TO A JURY TRIAL.
As used in paragraphs 7-12, the term “Company” is defined to include Sollis Health, as well as all parent, subsidiary, and affiliated corporations, associated or controlled companies, their successors, predecessors, and assigns, and all past and present officers, directors, agents, stockholders, partners, owners, representatives, employees, attorneys, and employees thereof, and other entities, assigns, and all persons acting on, by or through, under or in concert with them.
I understand and agree that the “Covered Disputes” that the Company and I agree to submit to binding arbitration include, without limitation, all claims, disputes, and/or controversies (except specifically excluded in paragraph 7) related in any way to my employment or my seeking employment and the termination of my employment, including, but not limited to, claims related to my compensation; claims of harassment, discrimination, retaliation, and wrongful discharge based on or arising from any federal, state, or local law, whether constitutional, statutory, or common law or regulation; and all claims arising from or based on Title VII of the Civil Rights Act, the Civil Rights Acts of 1866, 1871, 1971, and 1991, the Age Discrimination in Employment Act, the Older Workers Benefit Protection Act, the Americans with Disabilities Act, the Equal Pay Act, the Fair Labor Standards Act, the Family and Medical Leave Act, the Employee Retirement Income Security Act, the Worker Adjustment and Retraining Notification Act, the Immigration Reform and Control Act, the Genetic Information Nondiscrimination Act of 2008, the Vocational Rehabilitation Act, the Sarbanes-Oxley Act, the Families First Coronavirus Response Act, the Fair Credit Reporting Act, the California Private Attorneys General Act (“PAGA”); and, all claims based on all other federal, state, or local statutory or common laws or regulations which would otherwise require or allow me or the Company to seek a remedy in any court of law or other governmental dispute resolution forum between me and the Company.
By typing my electronic signature to this Agreement, I specifically understand and agree that all Covered Disputes required to be submitted to binding arbitration pursuant to this agreement shall be brought only in my individual capacity or that of the Company. My electronic signature represents my specific understanding and agreement that this binding arbitration agreement shall not be construed or interpreted to allow or permit the consolidation or joinder of other claims or controversies involving any other employees with my claims, or permit any claim I may have to proceed as a class action, collective action, or any similar representative action. I further understand and agree that no arbitrator shall have the authority under this Agreement to order or certify any such class, collective, or representative action. I agree that should I elect to pursue any non-individual private attorneys general act claims related to my employment with the Company, such claims will be stayed in court pending completion of the arbitration of any concurrently raised arbitrable disputes and individual claims covered by this Agreement.
In addition to requirements imposed by law, arbitration shall be conducted under the JAMS Employment Arbitration Rules & Procedures then in existence. The Company and I shall use the JAMS office in the city closest to the location of the Company site to which I applied or was hired, or such other mutually convenient location that the Company and I agree upon. Resolution of any Covered Dispute shall be based solely upon the law governing the claims and defenses pleaded, and the arbitrator may not invoke any basis (including but not limited to, notions of "just cause") other than such controlling law. The arbitrator shall have the immunity of a judicial officer from civil liability when acting in the capacity of an arbitrator, which immunity supplements any other existing immunity. Likewise, all communications during or in connection with the arbitration proceedings are privileged. As reasonably required to allow full use and benefit of this agreement, the arbitrator shall extend the times set for the giving of notices and setting of hearings. The arbitrator shall issue a written opinion setting forth the facts and law supporting any award. The Company shall pay the arbitrator’s fees and other costs relating to the arbitration forum, but I and the Company will be responsible for our own costs and for our attorneys’ fees should we choose to be represented by counsel, unless the arbitrator shifts one party’s costs and attorneys’ fees to the other party in accordance with applicable law. It is agreed that the Company shall not be responsible for paying the arbitrator’s fees and costs for the arbitration hearing sooner than 60 days before the commencement of the arbitration hearing. The arbitrator’s written decision shall be final, binding, and conclusive on the parties and may be entered in any court of competent jurisdiction.
Should any term or provision, or portion thereof of this arbitration agreement, be declared void or unenforceable, it shall be severed and the remainder of this agreement to arbitrate shall be enforceable. I understand and agree that no implied, oral, or written agreement contrary to the express language of this agreement to arbitrate is valid unless signed by both me and the Company’s Chief Executive Officer (CEO).
I acknowledge that this Agreement is not intended to interfere with my rights to collectively bargain, to engage in protected, concerted activity, or to exercise other rights protected under the National Labor Relations Act, and that I will not be subject to disciplinary action of any kind for opposing the arbitration provisions of this agreement.
Privacy Notice (for California applicants only)
Pursuant to the California Consumer Privacy Act (CCPA), the Company is notifying you that by applying for a position, you are providing us the following categories of personal information that we may use to evaluate your candidacy for employment, communicate with you regarding your candidacy, and obtain and verify background checks, and references: personal identifiers (e.g., name, SSN); contact information (e.g., mailing address, email, phone number), employment history (e.g., current and former positions held, work experience, and any certifications or licenses), and education history. By signing below, I acknowledge and confirm that I have received and read and understand this notice, and I authorize and consent to the Company’s use of the personal information it collects, receives, or maintains for the business purposes identified above.
DO NOT TYPE IN YOUR ELECTRONIC SIGNATURE BELOW UNTIL YOU HAVE READ THE ABOVE STATEMENT AND AGREEMENT. IF YOU HAVE ANY QUESTIONS REGARDING THIS STATEMENT, PLEASE ASK A COMPANY REPRESENTATIVE BEFORE SIGNING. BY TYPING IN YOUR ELECTRONIC SIGNATURE BELOW, YOU ACKNOWLEDGE THAT YOU HAVE FULLY READ AND UNDERSTAND THE ABOVE STATEMENT AND AGREEMENT.
MY TYPED ELECTRONIC SIGNATURE BELOW CONFIRMS THE FACT THAT I HAVE READ, UNDERSTAND, AND VOLUNTARILY AGREE TO BE LEGALLY BOUND TO ALL OF THE ABOVE TERMS. I FURTHER UNDERSTAND THAT THIS AGREEMENT REQUIRES THE COMPANY AND ME TO ARBITRATE ANY AND ALL DISPUTES THAT ARISE OUT OF MY APPLICATION FOR EMPLOYMENT AND EMPLOYMENT EXCEPT AS EXPRESSLY EXCLUDED HEREIN, AND THAT BOTH THE COMPANY AND I ARE GIVING UP OUR RIGHTS TO A TRIAL BY JURY.
Please type your full name below to agree to the above statement.
Voluntary Self-Identification For government reporting purposes, we ask candidates to respond to the below self-identification survey.
Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiring
process or thereafter. Any information that you do provide will be recorded and maintained in a
confidential file.
As set forth in Sollis Health’s Equal Employment Opportunity policy,
we do not discriminate on the basis of any protected group status under any applicable law.
Gender
Please select Male
Female
Decline To Self Identify
Are you Hispanic/Latino?
Please select Yes
No
Decline To Self Identify
Please identify your race
Please select American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Two or More Races
Decline To Self Identify
Race & Ethnicity Definitions
If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.
As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measure
the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categories
is as follows:
A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Veteran Status
Please select I am not a protected veteran
I identify as one or more of the classifications of a protected veteran
I don't wish to answer
Voluntary Self-Identification of Disability
OMB Control Number 1250-0005
Expires 04/30/2026
Why are you being asked to complete this form?
We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp .
How do you know if you have a disability?
A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
Alcohol or other substance use disorder (not currently using drugs illegally)
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
Blind or low vision
Cancer (past or present)
Cardiovascular or heart disease
Celiac disease
Cerebral palsy
Deaf or serious difficulty hearing
Diabetes
Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
Epilepsy or other seizure disorder
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
Intellectual or developmental disability
Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
Missing limbs or partially missing limbs
Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
Partial or complete paralysis (any cause)
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
Short stature (dwarfism)
Traumatic brain injury
Disability Status
Please select Yes, I have a disability, or have had one in the past
No, I do not have a disability and have not had one in the past
I do not want to answer
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