Application

It is the policy of this organization to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state, and local statutes, regulations, and ordinances.

This application to be active for a period of 90 days only.


PERSONAL INFORMATION
 * Required Fields
Date of application:
Attach Resume:  (optional)
Name (Last, First, Middle): *  ,    
Current Address: *
City, State, Zip: *  ,    

(Please enter previous address if at current address less than 12 months)
Previous Address:
Previous City, State, Zip:  ,    
Home Phone: *
Cell Phone:
Email:
Social Security Number:  
Are you at least 18 years old?

GENERAL INFORMATION
Current open position(s) you are applying for:
Type of position:
Salary Requirement:
Date available to work: *    MM/DD/YYYY
Shift desired:
Are you willing to travel?
If overtime work is required periodically, does this pose a problem for you?

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

Have you ever worked for Comprehensive Radiology Services or one of its affiliated physicians? *
If yes, give dates and position(s): 

Are you related to any employee of Comprehensive Radiology Services or one of its affiliated physicians?

Are you able to perform the essential, job related functions of the position for which you are applying with or without accomodations?
Describe any accomodations necessary:

How did you learn about this opening?



Are you currently excluded from participation in any federally funded healthcare program, including Medicare and Medicaid, and are you aware of any potential exclusion from a federally funded health program?

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense? *
If yes, give date, place, and nature of each such conviction:

Are you presently charged with any violation of the law? *
If yes, give date, place, and nature of such charge:

PROFESSIONAL INFORMATION
List any professional license, registration, or certification you possess (including drivers license,
Type:   State: 
Effective Date:  
Expiration Date:  
Number:  

EDUCATIONAL HISTORY
High School/GED:
City and State:
Degree or Certificate: Graduate?
Last year attended in school:

College:
City and State:
Degree or Certificate: Graduate?
Last year attended in school:

College:
City and State:
Degree or Certificate: Graduate?
Last year attended in school:

Other:
City and State:
Degree or Certificate: Graduate?
Last year attended in school:

EMPLOYMENT HISTORY
Please provide a minimum of the most recent 10 years employment history including any period of unemployment.
Current, or most recent employer: *
Address: *
City, State, Zip: *  ,    
Phone: *
Employed from: * to: *  ex: 6/1997 to 2/2003
Job title: *
Name while employed:
Ending salary: *
Immediate supervisor: *
Reason for leaving: *
Nature of duties and list of responsibilities: *
May we contact this employer? *

1st previous employer:
Address:
City, State, Zip:  ,    
Phone:
Employed from: to:  ex: 6/1997 to 2/2003
Job title:
Name while employed:
Ending salary:
Immediate supervisor:
Reason for leaving:
Nature of duties and list of responsibilities:
May we contact this employer?

2nd previous employer:
Address:
City, State, Zip:  ,    
Phone:
Employed from: to:  ex: 6/1997 to 2/2003
Job title:
Name while employed:
Ending salary:
Immediate supervisor:
Reason for leaving:
Nature of duties and list of responsibilities:
May we contact this employer?

3rd previous employer:
Address:
City, State, Zip:  ,    
Phone:
Employed from: to:  ex: 6/1997 to 2/2003
Job title:
Name while employed:
Ending salary:
Immediate supervisor:
Reason for leaving:
Nature of duties and list of responsibilities:
May we contact this employer?

PROFESSIONAL REFERENCES (other than relatives)
List three references that have good knowledge of your work.
Name:
Address:
City:    State: 
Home Phone:
Work Phone:
# of Years Known:

Name:
Address:
City:    State: 
Home Phone:
Work Phone:
# of Years Known:

Name:
Address:
City:    State: 
Home Phone:
Work Phone:
# of Years Known:

ACKNOWLEDGMENT AND AGREEMENT BY APPLICANT


In exchange for Comprehensive Radiology’s consideration of this employment application:

I promise that all information I have supplied in this application and any other forms, oral or written is true and accurate. I agree that any misstated, misleading, incomplete, or false information is grounds for rejection of this application form, refusal to hire, withdrawal of an offer of employment, or immediate discharge without notice or recourse, whenever and however discovered. I make this promise and agreement because I understand that Comprehensive Radiology Services will rely on my statements in deciding whether to hire me.

I hereby authorize Comprehensive Radiology Services and any agent acting on its behalf to conduct any background investigation it deems appropriate and hereby authorize and request former employers, personal references, schools, and law enforcement agencies to release any information that may be sought in connection with this application. I understand that I must submit to fingerprinting and a criminal record check pursuant to Section 43-11-13, the Mississippi Code of 1972, if I am offered and accept employment with the company. In addition, I release, acquit, and agree to hold harmless from any and all resulting liability, and covenant not to sue any former employer or other person or entities providing information sought in connection with this application. A copy of this agreement shall be deemed to serve the same purposes as the original.

I agree to submit myself upon request for a physical examination/drug screen to be conducted by a representative of Comprehensive Radiology Services. I agree also to such future physical examinations/drug screens as Comprehensive Radiology Services may require as a condition of continued employment. I agree that if I am offered employment, the offer will be contingent upon the results of the aforementioned physical examination/drug screen, replies from former employers and personal references, and the satisfactory completion of a six month probationary period. If, in the judgment of Comprehensive Radiology Services, misrepresentation by false statement, omission, or inaccuracy has been made by me in this application, or the results of such investigation as Comprehensive Radiology Services may conduct are not satisfactory, any offer of employment made by Comprehensive Radiology Services may be withdrawn or any employment terminated without any obligation or liability to me other than payment of earnings at the rate agreed upon through the last day of employment. I further agree to the search of myself or personal property on the company’s premises or while conducting business elsewhere.

If employed, I agree to acquaint myself with and abide by all rules, regulations, and employee relations, policies as established or amended by this company. I further agree that any employment resulting from this application may be terminated at any time, for any reason, with or without cause or notice, and without liability to me for wages, salary, or other benefits except such wages specifically earned at the time and date of such termination. I understand that my completion of this application does not mean a job opening exists and in no way obligates Comprehensive Radiology Services to interview or employ me.

I hereby authorize Comprehensive Radiology Services to release to other prospective employers any information regarding my employment with the company including the information set forth in this application or obtained by the company from sources names by me herein, whether or not this information is in the company’s records. I hereby release, acquit, and agree to hold harmless from any and all resulting liability, and covenant not to sue Comprehensive Radiology Services in connection with releasing such information.



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