On-Line Imaging Application For Employment
 
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Position(s) Applied For:
 Date Available to Start Work:
 Date of Application:
Minimum Salary Requirement:  
  Hourly  Annual		 Work Availability (check all that apply):
Part Time  Full Time  Casual		 Shift Availability (check all that apply):
Day  Evening  Night  Weekend
How did you learn about the position?  
         
Personal Information  
Last Name:
 First Name:
 Middle Name:
Street Address:
 City:
 State:
 Zip:
Home Phone:
 Other Phone:
 e-Mail Address:
Any special training or skills (languages, machine operations, etc.)?
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Have you previously applied for employment with On-Line Imaging? Yes  No
If Yes, give date(s) and position(s):
  
Have you ever been employed by On-Line Imaging? Yes  No
If Yes, give date(s) and position(s):
  
Do you have any friends or relatives that work for On-Line Imaging? Yes  No
If Yes, state name and relationship:
  
Are you currently employed? Yes  No
May we contact your current employer? Yes  No
If No, why?
  
Have you ever been bonded? If Yes, when and where. Yes  No
Will you work overtime if asked? Yes  No
Are you prevented from lawfully becoming employed in the United States because of Visa or Immigration Status?
(Proof of citizenship or immigration status will be required upon employment.)		 Yes  No
Have you ever been arrested or convicted of any crimes, including misdemeanors and/or felonies? Yes  No
If Yes, please explain: (Such arrests or convictions may be relevant if job related, but would not automatically bar you from employment. Each case is considered individually)
  
If you are licensed, registered or otherwise credentialed, have you ever been suspended, placed on probations
or had other disciplinary actions taken against you?		 Yes  No
If Yes, please explain:
  
       
References  
Name: Telephone Number: Years Known: Occupation/Company/Relationship:
 
 
 
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Education       
High School: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Vocational/Technical School: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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College: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Other: Number of Years Attended: Did you Graduate?
YesNo
Street Address: City: State: Zip:
Course of Study: List Degrees/Licensure/Certifications:

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Work Experience     Please give an accurate, complete full and part-time employment record. Start with your most recent position.
Company Name (1): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (2): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (3): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Company Name (4): Name of Supervisor: Telephone Number:
Street Address: City: State: Zip:
Employed From: Employed To: Pay Start: Pay Finish:
Position Title - Work Performed Reason for leaving:

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Military  
Have you or do you serve in the U.S. Armed Forces?  Yes  No
If "Yes" in what Branch did you serve?
Describe any training you received relevant to the position for which you are applying:

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License/Certifications         
Type: State: Date Issued: Date Expired: Registration Number:
BLS
ACLS
   
Skills/Information:     Describe any additional specialized training or skills you would like us to consider as a part of your application.

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Other Activities: List  professional, trade business or other civic activities and offices held. You may exclude any information that would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

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Applicant Information     Please read and understand the statement below before signing you application.

 
   The information I have provided to On-Line Imaging in this Application for Employment ("Application") is true, correct and complete. I understand that false, incomplete or misrepresented information of any kind, will be sufficient cause for my Application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

   I authorize On-Line Imaging to contact and obtain information about me from previous employers, educational institutions and references I provided, and any other party necessary to verify the accuracy of information I disclosed in this Application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against On-Line Imaging and all other persons, corporations or organizations who provides information for this purpose. I agree that if I've been convicted of a crime, the authorities of On-Line Imaging may obtain the details of my conviction to determine its relationship to the position I'm applying for a condition of my employment.

   Any offer of employment I may received is contingent upon my successful completion of the pre-employment screening process, including On-Line Imaging receiving references that it considers satisfactory and my satisfactory completion of any post-job offer pre-employment physical examination which the employer may require.

   If hired, I agree to comply with On-Line Imaging's policies, rules, regulations and procedures, and I understand that my employment would be "at will". This means that, just as I am free to resign at any time, On-Line Imaging reserves the right to terminate my employment at any time for any reason and without prior notice. This Application is not an employment agreement. I understand that no one, other than an executive officer of On-Line Imaging, has authority to enter into any employment agreement with terms contrary to the foregoing and then only if the agreement is in writing and sighed by such officer.

   I fully understand and accept all terms and conditions in the above statement.

 
Applicant Signature
 Date
 
 
 
 

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If you have any questions, please contact us at 402.334.7005.


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