Employment Application

Please have all the information necessary to complete this application ready before you begin to avoid timing-out.

IDENTIFICATION
Name (first, middle, last): Social Security #: Home Phone:
Cell Phone: Address: City:
State: Zip: Email:
May we contact you via email?    

POSITION
Position Applied For: Expected Pay/Salary: Date Available:
How were you referred?
Available For: Overtime? Yes No
 Can you work any shift?:
 Yes No
Part-Time # of Hours: What span of hours can you work?

GENERAL INFORMATION
Are you at least 18 years or older? (If no, you may be required to provide authorization to work.) Yes No
Are you eligible to work in the United States? Yes No
Have you ever worked in this firm before? Yes No
Do you know anyone who works for our firm currently and/or previously? Yes No
If yes, please list their name(s):
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? Yes No
Will you travel if position requires? Yes No
If yes, up to what percentage of time?:
Have you ever been fired from a position? Yes No
If yes, please provide details:  
In the last ten years, have you ever been convicted of a crime other than minor traffic offense? Yes No
If yes, please provide details:  

EDUCATION
  School Name/Location # Years Attended Major Coursework Any Degree Received?
High School
College or University
Vocational, Trade or Business School

Do you have any special skills, experience and/or training that would enhance your ability to perform the position applied for? If yes, explain.

Computer/Software Skills (please describe):

EMPLOYMENT HISTORY

List your employment history beginning with the most recent employment first.
COMPLETE THIS SECTION IN ADDITION TO ANY RESUME YOU MAY SUBMIT.
Employer's Name: Address: Phone:
Employment Dates: to Base Salary:
Reason for Leaving:
Summarize the work and job responsibilities:
Supervisor's Name: Other Cash Compensation:
Special Training Received:

 
Employer's Name: Address: Phone:
Employment Dates: to Base Salary:
Reason for Leaving:
Summarize the work and job responsibilities:
Supervisor's Name: Other Cash Compensation:
Special Training Received:

 
Employer's Name: Address: Phone:
Employment Dates: to Base Salary:
Reason for Leaving:
Summarize the work and job responsibilities:
Supervisor's Name: Other Cash Compensation:
Special Training Received:

REFERENCES

List individuals personally acquainted with your work performance other than supervisors listed above. 

Name Relationship Contact Information

RESUME

Please copy and paste a plain text version of you resume below:

CERTIFICATION: Read the following carefully before submitting

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents including a resume) is correct, accurate and complete to the best of my knowledge.  I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Advanced Medical Imaging, RAPC or its subsidiaries, that such employment is at will, for no specified duration and may be terminated by either the company or myself at any time, with or without cause or notice

I understand that if offered a position, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment.  I understand that unsatisfactory results; refusal to cooperate, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to ABC and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

By signing below I acknowledge that I have read, understood and agree to the above statements.

Applicant Signature: (typing your name here will substitute your signature) Date:

Advanced Medical Imaging is proud to be an EEO Employer.
We are committed to maintaining a drug-free workplace and perform pre-employment substance abuse testing and appropriate background checks.