Employment Application

* indicates a required field


Date:
*Name:
*Home Address:
*City:
*State:
Home Phone:
Cell Phone:
Pager:
*Email:
Social Security #:
Job Title: Other Job Title:
JOB INTEREST
Date Available:
How many days a week are you interested in working?:
Are you interested in covering any on-call shifts including after hours and weekends?:
How far are you willing to commute to an assignment?:
What shift are you interested in?:
PROFESSIONAL LICENSES AND CERTIFICATES
Type of License: Number: State Issued: Expiration:
Type of License: Number: State Issued: Expiration:
Do you have an ACLS Card?
Yes
No If yes, when does it expire?:
Do you have an BLS Card?
Yes
No If yes, when does it expire?:
Do you have any other Licenses, Certificates or special training that would be pertinent to the position in which you are applying?
 
Have you ever been convicted of a felony? If yes, please explain:
 
Are you legally eligible for employment in this country?
Yes
No
EMPLOYMENT HISTORY
List your last three employers starting with the most recent
EMPLOYER: Dates Employed From: To:
Address:
Telephone: Supervisor:
Reason for Leaving:
Job Description and Duties:
 
May we contact this employer?
Yes
No
Ending Pay (Monthly, Hourly):
 
EMPLOYER: Dates Employed From: To:
Address:
Telephone: Supervisor:
Reason for Leaving:
Job Description and Duties:
 
May we contact this employer?
Yes
No
Ending Pay (Monthly, Hourly):
 
EMPLOYER: Dates Employed From: To:
Address:
Telephone: Supervisor:
Reason for Leaving:
Job Description and Duties:
 
May we contact this employer?
Yes
No
Ending Pay (Monthly, Hourly):
EDUCATIONAL BACKGROUND
School:
Degree / Diploma:
Dates Attended From:      To:
# of years completed:
 
School:
Degree / Diploma:
Dates Attended From:      To:
# of years completed:
 
School:
Degree / Diploma:
Dates Attended From:      To:
# of years completed:
SPECIAL SKILLS & TRAINING
List the Cath Lab monitoring systems that you have used in the past and are familiar with:
 
List the radiology equipment you have used in the past and are familiar with:
 
Please present any additional information concerning your work interests, experience, or hobbies related to the position you are seeking which you believe will be helpful to us in evaluating your qualifications:
 
REFERENCES
Name:
Telephone:
# years known:
 
Name:
Telephone:
# years known:
 
Name:
Telephone:
# years known:

YOU ARE HEREBY AUTHORIZED TO INVESTIGATE ANY INFORMATION PROVIDED IN THIS APPLICATION FOR EMPLOYMENT, TO EMPLOY ANY AGENT OF YOUR CHOICE TO UNDERTAKE ANY SUCH INVESTIGATIONS AND TO COMMUNICATE WITH ANY PERSON IN MAKING SUCH AN INVESTIGATION, INCLUDING BUT NOT LIMITED TO ANY OR ALL OF MY PREVIOUS EMPLOYERS, SCHOOLS, OR OTHER ENTITIES LISTED HEREIN. I AUTHORIZE THE EMPLOYERS, SCHOOLS AND ALL OTHER PERSONS AND ENTITIES NAMED IN THE APPLICATION TO RELEASE ANY INFORMATION TO APEX STAFFING SERVICE RELEVANT TO THIS APPLICATION FOR EMPLOYMENT. I RELEASE APEX STAFFING SERVICE AND ITS EMPLOYEES AND ALL OTHER EMPLOYERS, SCHOOLS, OTHER ENTTIES AND PERSONS WITH WHOM APEX STAFFING SERVICE SO COMMUNICATED OR WHO PROVIDE INFORMATION TO APEX STAFFING SERVICE FROM ANY LIABILITY WHATSOEVER WHICH MAY RESULT FROM COMMUNICATION AND THE USE, RELEASE OR DISCLOSURE OF ANY INFORMATION.