Employment Application Form General Information First Name* Last Name* Middle Initial Address (Mailing Address)* City* State* Zip* Home Telephone* Mobile Telephone Email* Are you legally eligible to work in the U.S.?*YesNo Have you previously been employed by RDC?*YesNo [group previously-employed-selected] What position(s) and when? [/group] Are any relatives currently employed by RDC?*YesNo [group relatives-employed-selected] What position? [/group] Have you ever been convicted of a crime under your own or another name? (conviction of a crime or crimes will not neccessarily disqualify you from employment) *YesNo [group crime-selected] Please explain: [/group] Position Position Desired * Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?*YesNo Will Accept:*Part-TimeFull-TimeTemporary Shift:*DaysEveningsWeekends Education High School Graduate or General Education (GED) Test Passed?*YesNo Name and Location Degree Program Major GraduateYesNo Year Name and Location Degree Program Major GraduateYesNo Year Name and Location Degree Program Major GraduateYesNo Year Name and Location Degree Program Major GraduateYesNo Year College, Business, Vocational School (Most recent first) Occupational License, Certificate or Registration Number Where Issued Expiration Date Occupational License, Certificate or Registration Number Where Issued Expiration Date Occupational License, Certificate or Registration Number Where Issued Expiration Date Languages Read, Written or Spoken Fluently Other Than English Special Skills (List all pertinent skills and equipment that you can operate) Work Experience Current Employer Telephone Number Address Job Title Number Employees Supervised From (Month/Year) To (Month/Year) Duties Reason for Leaving May We Contact This Employer?YesNo Previous Employer Telephone Number Address Job Title Number Employees Supervised From (Month/Year) To (Month/Year) Duties Reason for Leaving Previous Employer Telephone Number Address Job Title Number Employees Supervised From (Month/Year) To (Month/Year) Duties Reason for Leaving Previous Employer Telephone Number Address Job Title Number Employees Supervised From (Month/Year) To (Month/Year) Duties Reason for Leaving References (Provide three professional references) Name Relationship Contact Address Contact Phone Number Name Relationship Contact Address Contact Phone Number Name Relationship Contact Address Contact Phone Number How did you hear about this position? RDC WebsiteRadio/TVInternet Job PostingAgencyEmployee ReferralNewspaperOther Name I hereby certify that all entries in this application and any attachments are true and complete, and I agree and understand that any falsification or omission of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment. I understand that all information in this application is subject to verification and I consent to any investigation of my personal history including but not limited to employment and education. I also understand that a credit check will be required if position for employment is of a financial nature or one with access to the personal financial information of another person. I also consent that the employer may contact references, former employers and education institutions listed regarding this application. I further authorize the employer to rely upon and use, as it sees fit, any information received from such contacts. I further understand that this application is not, and is not intended to be, a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. My employment is not for any specific length of time. The relationship is and will always be one of voluntary employment "at-will". I am free to resign at any time, with or without notice for any reason or no reason. Similarly, the company is free to conclude an employment relationship at any time it believes it is in the company's best interest to do so with or without notice, for any reason or no reason. Reno Diagnostic Centers is an equal opportunity employer and is firmly committed to the policy of non-discrimination, equal opportunity and reasonable accommodation in employment. I understand that all information in this application is subject to verification and I consent to any investigation of my personal history including but not limited to employment and education. I also understand that a credit check will be required if position for employment is of a financial nature or one with access to the personal financial information of another person. I also consent that the employer may contact references, former employers and education institutions listed regarding this application. I further authorize the employer to rely upon and use, as it sees fit, any information received from such contacts. I further understand that this application is not, and is not intended to be, a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. My employment is not for any specific length of time. The relationship is and will always be one of voluntary employment "at-will". I am free to resign at any time, with or without notice for any reason or no reason. Similarly, the company is free to conclude an employment relationship at any time it believes it is in the company's best interest to do so with or without notice, for any reason or no reason. Reno Diagnostic Centers is an equal opportunity employer and is firmly committed to the policy of non-discrimination, equal opportunity and reasonable accommodation in employment. Signature of Applicant* Date*
