Employment Application

 General Information
  Name:    
  Address:    
  City:    
  State:    
  Zip    
  Phone:     -
  Work Phone:     -
  Background Information
  Do you have a valid Driver's License? Yes No     Driver's License State/#
  Have you ever applied to, or worked for MD Imaging?     If yes, when: MM/YYYY
/
  Do you have any friends or relatives working for MD Imaging?     If yes, state name & relationship
  How did you hear about us/this opening?    
  State briefly why you would like to work for MD Imaging?    
  Are you over eighteen years of age?     Yes No
 

Have you ever been convicted of a felony (excluding any sealed or expunged convictions)?
(NOTE: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

    If yes, please explain:
  Are you able to produce valid identification and proof of legal residence?     Yes No
  Are you able to perform the essential functions of the job with or without reasonable accommodations?     Yes No
  If no, what type of accommodation would enable you to perform the job?    
 

General Information About Employment Desired
  Position you are applying for?     Full-time/Part-time:
  If part-time, hours per week desired:     Are you available for work on weekends?
Yes No
  Are you available to work holidays?     Yes No
  Days of week you are available to work:    
  Hours you are available to work:     Are you available to be on-call?
Yes No
  Are you available to work evenings and nights?     Yes No
  Are you available to work overtime?     Yes No
  If hired, on what date could you start work?     DD/MM/YYYY / /
  Are you able to travel on company business?     Yes No
  % time willing to travel:    
  Hourly rate of pay or monthly salary desired:    
  Education and training (Including on-the-job training):
    School/Location/Sponsor Course of Study Dates Attended (MM/YYYY)
  High School / to /
  Community College / to /
  Trade School / to /
  College/University / to /
  Seminars/Other / to /
  Special Skills:
  Do you speak, write or understand any foreign languages?     Yes No
  If yes, which language(s)?    
  Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at MD Imaging?     Yes No
  If so, explain in detail:    
  Computer Skills Dates Used (MM/YYYY) Level of Proficiency
  Hardware: / to /
  Hardware: / to /
  Software: / to /
  Software: / to /
 

Summarize other relevant experience, skills and background:

   
  Employment History:
  Employment Occupation #1
  Name of Company:    
  Name of Supervisor:    
  Address:    
  City:    
  State:    
  Zip:    
  Phone:     -
  Position    
  Duties:    
  Dates of Employment (MM/YYYY):     / to /
  Starting Rate of Pay:      Ending Rate of Pay:
  Reason for Leaving:    
  Employment Occupation #2
  Name of Company:    
  Name of Supervisor:    
  Address:    
  City:    
  State:    
  Zip:    
  Phone:     -
  Position    
  Duties:    
  Dates of Employment: (MM/YYYY)     / to /
  Starting Rate of Pay:      Ending Rate of Pay:
  Reason for Leaving:    
  Employment Occupation #3
  Name of Company:    
  Name of Supervisor:    
  Address:    
  City:    
  State:    
  Zip:    
  Phone:     -
  Position    
  Duties:    
  Dates of Employment: (MM/YYYY)     / to /
  Starting Rate of Pay:      Ending Rate of Pay:
  Reason for Leaving:    
  Terms & Conditions
  I have read and agree to the Terms & Conditions
  Resume (Optional)
  Upload Document (*.DOC, *.PDF, *.RTF)