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Online Employment Application

Date of Application:
Name:
Address:
Telephone:
Cellular/Other Phone:
E-mail Address:
Position(s) applied for: MRI Tech CT Tech X-Ray Ultrasound Tech Nuclear Medicine Tech Front Desk
Medical Assistant Accounting Administrative Assistant Management Marketing Rep
Authorizations Billing

Have you submitted an employment application to Rose Radiology Centers before? Yes  No
If yes, give date(s) and position(s):

Have you ever been employed by Rose Radiology Centers?  Yes  No
If yes, date(s) and position(s):

Are you legally eligible for employment in this country?  Yes  No

Date available for work: / /

What is your desired salary range or hourly rate of pay?     $    Per

Have you ever pleaded “guilty” or “no contest” to or been convicted of a crime?  Yes  No

If yes, please provide date(s) and details:

Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for Rose Radiology Centers? Yes  No

If yes, please explain:


EMPLOYMENT HISTORY


List most recent first.

Employer #1

Employer Telephone #

City State

Starting Job Title Final Job Title

Dates employed:  Month / Year TO Month / Year

Compensation (Starting) Hourly Salary  $    Per

Compensation (Final)    Hourly Salary   $    Per

Commission / Bonus / Other Compensation   $    Per

Immediate supervisor and title (most recent title):

Can we contact for reference?  Yes  No Later      Email

Summarize the type of work performed and job responsibilities:

What did you like most about your position?

What were the things you liked least about the position?

Employer #2

Employer Telephone #

City State

Starting Job Title Final Job Title

Dates employed:  Month / Year TO Month / Year

Compensation (Starting) Hourly Salary  $    Per

Compensation (Final)    Hourly Salary   $    Per

Commission / Bonus / Other Compensation   $    Per

Immediate supervisor and title (most recent title):

Can we contact for reference?  Yes  No Later      Email

Summarize the type of work performed and job responsibilities:

What did you like most about your position?

What were the things you liked least about the position?

Employer #3

Employer Telephone #

City State

Starting Job Title Final Job Title

Dates employed:  Month / Year TO Month / Year

Compensation (Starting) Hourly Salary  $    Per

Compensation (Final)    Hourly Salary   $    Per

Commission / Bonus / Other Compensation   $    Per

Immediate supervisor and title (most recent title):

Can we contact for reference?  Yes  No Later      Email

Summarize the type of work performed and job responsibilities:

What did you like most about your position?

What were the things you liked least about the position?


SKILLS and QUALIFICATIONS
Summarize any special training, skills, licenses and/or certificates that may assist you in performing the position for which you are applying:

COMPUTER SKILLS (check appropriate boxes. Include software titles and years of experience)

Word Processing
Spreadsheet
Presentation
Email
Internet
Other
Other
Other


EDUCATIONAL BACKGROUND

Starting with your most recent school attended, provide the following information.

School #1

School Name:

City: State:

Years Completed:

Completed:

Diploma
GED
Degree
Certification
Other

Major / Minor:

 

School #2

School Name:

City: State:

Years Completed:

Completed:

Diploma
GED
Degree
Certification
Other

Major / Minor:

 

School #3

School Name:

City: State:

Years Completed:

Completed:

Diploma
GED
Degree
Certification
Other

Major / Minor:

School #4

School Name:

City: State:

Years Completed:

Completed:

Diploma
GED
Degree
Certification
Other

Major / Minor:


REFERENCES
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors.
If not applicable, list three school or personal references who are not related to you.

Reference #1
Name:
Title:
Relationship to You:
Telephone:
E-mail:
# of Years Known:

Reference #2
Name:
Title:
Relationship to You:
Telephone:
E-mail:
# of Years Known:

Reference #3
Name:
Title:
Relationship to You:
Telephone:
E-mail:
# of Years Known:


APPLICANT STATEMENT
I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct.
I understand that Rose Radiology Centers, Inc. is a drug-free workplace and performs drung testing on all candidates offered a position, prior to hire.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview.  I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this employer does not unlawfully discriminate in employment and no questions on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days.  At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law.  This application does not constitute an agreement or contract for employment for any specified period or definite duration.  I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I understand that if I am hired, my employment will be subject to a probationary period, which ordinarily will not exceed 90 days from the date I am hired. If I am discharged at any time during the probationary period for unsatisfactory performance, I understand that this employer will not be charged for and unemployment benefits that may be paid to me for work performed during the probationary period.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration for employment on the basis of his or her sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic materials, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as a vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration for employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

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