PROSCAN IMAGING AND AFFILIATES
Employment Application
APPLICATION INFORMATION
Last Name
First Name
M.I
.
Date of Submission
Street Address
Apartment/Unit #
City
State
Zip Code
Phone
E-mail Address
Date Available
Desired Salary
Position Applying For
Are you a citizen of the United States?
YES
NO
If no, are you authorized to work in the US?
YES
NO
Have you ever worked for this company?
YES
NO
If so, when?
Have you ever been convicted of a felony?
YES
NO
If yes, Explain:
Have you ever been excluded from participating in any Medicare, Medicaid, or any Federal Healthcare Programs or excluded or debarred from any other Federal program?
YES
NO
If yes, Explain:
List all surnames which you may have been previously know by (Prior maiden name, married name, etc...)
*Please submit a current resume or continue with filling out application below
SUBMIT RESUME
EDUCATION
High School
Address
From
To
Did you graduate?
YES
NO
College
Address
From
To
Did you graduate?
YES
NO
Degree
Other
Address
From
To
Did you graduate?
YES
NO
Degree
REFERENCES
Please list two professional references
Full Name
Relationship
Company
Phone
Full Name
Relationship
Company
Phone
PREVIOUS EMPLOYMENT
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
YES
NO
MILITARY SERVICE
Branch
From
To
Rank at Discharge
Type of Discharge
If other than honorable, explain
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Prospective employees will receive consideration without discrimination based on race, creed, color, sex, age, national origin, handicap, veteran status or any condition prescribed by state of local law.
All material ©2008 Proscan Imaging. All Rights Reserved.