Member Login                                                                PROSCAN IMAGING AND AFFILIATES Employment Application APPLICATION INFORMATION Last Name  First Name  M.I.  Date of Submission Street Address  Apartment/Unit # City  State  Zip Code Phone  E-mail Address Date Available   Desired Salary Position Applying For Are you a citizen of the United States? YES NO  If no, are you authorized to work in the US? YES NO Have you ever worked for this company? YES NOIf so, when? Have you ever been convicted of a felony? YES NO If yes, Explain: Have you ever been excluded from participating in any Medicare, Medicaid, or any Federal Healthcare Programs or excluded or debarred from any other Federal program?YES NO If yes, Explain: List all surnames which you may have been previously know by (Prior maiden name, married name, etc...)   *Please submit a current resume or continue with filling out application below    SUBMIT RESUME  EDUCATION High School   Address From To  Did you graduate? YES NO College  Address From  To   Did you graduate? YES NO Degree Other  Address From  To   Did you graduate? YES NO Degree REFERENCES Please list two professional references Full Name  Relationship Company  Phone Full Name  Relationship Company  Phone PREVIOUS EMPLOYMENT Company   Phone Address  Supervisor Job Title  Starting Salary  Ending Salary Responsibilities From   To  Reason for Leaving May we contact your previous supervisor for a reference? YES NO Company   Phone Address  Supervisor Job Title  Starting Salary  Ending Salary Responsibilities From   To  Reason for Leaving May we contact your previous supervisor for a reference? YES NO Company   Phone Address  Supervisor Job Title  Starting Salary  Ending Salary Responsibilities From   To  Reason for Leaving May we contact your previous supervisor for a reference? YES NO MILITARY SERVICE Branch  From   To Rank at Discharge  Type of Discharge If other than honorable, explain DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Prospective employees will receive consideration without discrimination based on race, creed, color, sex, age, national origin, handicap, veteran status or any condition prescribed by state of local law.   Terms of Use Privacy Statement HIPAA Privacy Practices Careers Site Map Copyright © 2010 by ProScan Imaging