On-Line ImagingApplication for Employment
Prospective employees will receive consideration without regard to race, color, sex, age, national origin, disability or any protected
status under federal, state or local law.
Position(s) Applied For:  
 Date Available to Start Work    ?mm/dd/yyyy
 Date of Application    ?mm/dd/yyyy
Minimum Salary Requirement:    Hourly
  Annual		 Work Availability (check all that apply):
Part Time  Full Time  Casual		 Shift Availability (check all that apply):
Day  Evening  Weekends
     
 Personal Information 
Last Name, First Name Middle Name (ex: Smith, John Paul)
Street Address
 City
 State
 Zip
Home Phone
 Other Phone
 e-Mail Address
 Social Security Number
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 an 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?    
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.)  		  
    
 References 
NameTelephone NumberYears KnownOccupation/Company/Relationship

 Education        
Name & Location Did you Graduate? # of Years List Degrees/Licensure/Certifications Course of Study
High School
 YesNo
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City/State/Zip
Vocational/Technical School
 YesNo
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City/State/Zip
College
 YesNo
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City/State/Zip
Other
 YesNo
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City/State/Zip
         
 Work Experience  Please give an accurate, complete full and part-time employment record. Start with your most recent position.
Company Name
 Employed (include month & year)
From    To 
Address
 Pay   Start    Finish  Annual  Hourly
Name of Supervisor
 Telephone Number
 Describe Work Performed

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Job Title
 Reason for Leaving
         
Company Name
 Employed (include month & year)
From    To 
Address
 Pay   Start    Finish  Annual  Hourly
Name of Supervisor
 Telephone Number
 Describe Work Performed

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Job Title
 Reason for Leaving
         
Company Name
 Employed (include month & year)
From    To 
Address
 Pay   Start    Finish  Annual  Hourly
Name of Supervisor
 Telephone Number
 Describe Work Performed

200 characters left
Job Title
 Reason for Leaving
         
Company Name
 Employed (include month & year)
From    To 
Address
 Pay   Start    Finish  Annual  Hourly
Name of Supervisor
 Telephone Number
 Describe Work Performed

200 characters left
Job Title
 Reason for Leaving
     
 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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 Other Skills/Information  Describe any additional specialized training, apprenticeships or skills you would like us to
 consider as a part of your application.

200 characters left
   
 Other Activities  List professional, trade business or other civic activities and offices held. You may exclude any information that
 would reveil gender, race, religion, naitonal origin, age, ancestry, disability or other protectes status.

200 characters left
     
 Applicant Information  Please read and understand this statement below before signing you application.

 
   I certify that the facts contained in this applicatoin are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

   I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

   I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
 
Applicant Signature
 Date