Physician Assistant or Nurse Practitioner - Emergency - Per Diem

1. Please, input Yes or No below

2. If yes, please explain further

1. Please, input Yes or No below

2. If yes, please explain further

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

1. 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

2. 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. 

3. 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.

4. 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

5. 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 of claims arising under the National Labor Relations Act which are brought before the National Labor Relations Board, claims for medical and disability benefits under Workers' Compensation, unemployment compensation claims filed with the state, any claim, dispute, and/or controversy on an individual basis only which are brought properly in, and only to the extent they remain in, small claims court, or other claims that are not subject to arbitration under law, including but not limited to claims for sexual harassment and/or sexual assault brought under state or federal law unless I voluntarily elect to submit such claims to arbitration.  Moreover, nothing herein shall prevent me from filing a charge or complaint with the United States Equal Employment Opportunity Commission or a similar state or local agency that allows me to file an administrative charge or complaint (although if I choose to pursue a claim following the exhaustion of such administrative remedies, that claim shall be subject to the arbitration provisions explained herein).  I also understand that the Company also 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.

6. 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.

7. 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.

8. 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. 

9. 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.

10. 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).

11. 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)

12. 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.