Applicant Information Applicant InformationLast Name*FIrst Name*Middle InitialAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Address* Date Available* Date Format: MM slash DD slash YYYY Desired Salary*Position Applied For*Are you a citizen of the United States?*YesNoAre you authorized to work in the U.S.?YesNoHave you ever worked for our Company?*YesNoWhen?EducationHigh SchoolAddressDid you graduate?YesNoDegreeCollegeAddressNumber of Years CompletedDegreeOther SchoolAddressNumber of Years CompletedDegreeEmployment HistoryCompanyPhoneAddressSupervisorJob TitleEnding SalaryResponsibilitiesFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor?YesNoCompanyPhoneAddressSupervisorJob TitleEnding SalaryResponsibilitiesFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor?YesNoCompanyPhoneAddressSupervisorJob TitleEnding SalaryResponsibilitiesFrom Date Format: MM slash DD slash YYYY To Date Format: MM slash DD slash YYYY Reason for LeavingMay we contact your previous supervisor?YesNoWork Related ReferencesPlease list three professional references.Full NameRelationshipCompanyPhoneAddressFull NameRelationshipCompanyPhoneAddressFull NameRelationshipCompanyPhoneAddressAdditional InformationHow were you referred to us?Have you ever applied to our company before?YesNoPlease list any relatives employed by usAre you over 18 years of age?YesNoOnly U.S. Citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon hire, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?YesNoHave you been convicted of a crime (other than minor traffic violations) or are you awaiting trial for a crime?YesNo(An affirmative response will not automatically disqualify you from being considered as a candidate for employment.)If "yes" please explainAre you available to work any shift?YesNoCommentsAny day of the week?YesNoCommentsAre you willing to work overtime as required?YesNoDisclaimer and SignatureI certify that my answers are true and complete to the best of my knowledge. Any misrepresentation or omission of facts in my application, attachments to my application or interview may result in refusal of employment or if employed, termination from employment.Signature*Type your name to apply your signature.In exchange for the consideration of my job application by Pueblo Medical Imaging (hereinafter called “the Company”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Pueblo Medical Imaging, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President or Practice Administrator of the Company. Both the undersigned and Pueblo Medical Imaging may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract. I also understand the (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I understand that, in connection with the routine processing of your employment application, the Company may request a Background Check including Criminal Felony & Misdemeanor, National Sex Offender Registry, Social Security Number Validation, Social Security Trace, Health Care Sanctions, Credit report, Employment report, Education report and Global Sanctions & Enforcement. I further understand that my employment with the Company shall be introductory for a period of ninety (90) days, and that at any time during the introductory period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. Signature*Type your name to apply your signature.This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications. Thank you for completing this application form and for your interest in our business.E-Verify is an Internet-based system that compares information from an employee's Form I-9, Employment Eligibility Verification, to data from U.S. Department of Homeland Security and Social Security Administration records to confirm employment eligibility. NameThis field is for validation purposes and should be left unchanged.