Employment

Applicant Name*

First Last

Home Address*

Street Address City State ZIP Code

Number of years at this address*

Daytime Phone*

Evening Phone

Mobile Phone

Do you have a valid Driver's License?*

Yes
No

Job position applied for:

Full or Part Time?*

Full Time
Part Time

Desired Salary

Who referred you to our company?

Do you have any friends or relatives who work here? If yes, please list here:

Have you applied to our company previously?*

Yes
No

If yes, when?

Are you at least 18 years old?*

Yes
No

Are you willing to work any shift, including nights and weekends?*

Yes
No

If no, please state any limitations:

If applicable, are you available to work overtime?*

Yes
No

If you are offered employment, when would you be available to begin work?*

If hired, are you able to submit proof that you are legally eligible for employment in the United States?*

Yes
No

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?*

Yes
No

What reasonable accommodation, if any, would you request?

Have you ever been convicted of a felony or misdemeanor?*

The existence of a criminal record does not constitute an automatic bar to employment unless relevant to the type of employment.

Yes
No

If yes, please state what you were convicted of and when:

Applicant Skills

Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and rate your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)

Skill

Typing

Years of Experience

Ability or Rating

Microsoft Office Suite (Word, Excel, etc)

Answering Telephones

Customer Service

Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. I

Employer Name

Supervisor Name

Address

Street Address City State ZIP Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

Would you like to add another employer?

Employer Name

Supervisor Name

Address

Street Address City State ZIP Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

Would you like to add another employer?

Employer Name

Supervisor Name

Address

Street Address City State ZIP Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

Would you like to add another employer?

Employer Name

Supervisor Name

Address

Street Address City State ZIP Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

Would you like to add another employer?

Employer Name

Supervisor Name

Address

Street Address City State ZIP Code

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

Applicant's Education and Training

College/University Name and Address

Did you receive a degree?

Yes
No

If yes, degree(s) received:

High School/GED Name and Address

Did you receive a degree?

Yes
No

Other Training (graduate, technical, vocational):

Please indicate any current professional licenses or certifications that you hold:

Awards, Honors, Special Achievements:

Military Service:

Yes
No

Branch of Military

Specialized Training:

References

List any two non-relatives who would be willing to provide a reference for you.

Name

First Last

Address

Street Address City State ZIP Code

Phone

Relationship

Name

First Last

Address

Street Address City State ZIP Code

Phone

Relationship

Emergency Contact

Who should be contacted if you are involved in an emergency?

Emergency Contact Name*

First Last

Relationship to You*

Address

Street Address City State ZIP Code

Daytime Phone*

Evening Phone

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:

Upload Resume (optional)

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Mobile X-Rays On Demand L.L.C. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its Owner, the employment relationship will be "at-will". In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Mobile X-Rays On Demand L.L.C., except in a specific written contract of employment signed on behalf of the organization by its Owner, has the power to alter or vary the voluntary nature of the employment relationship.

*

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.

Applicant Skills

Applicant Employment History

Applicant's Education and Training

References

Emergency Contact

Certification

Testimonial