Interventional Radiology Clinic RN - BAMC

First name*

Last name*

Email address*

Location

Phone number*

Resume*

Have you worked for this company before? If so, when?
How did you hear about GiaMed?If referred, by whom?*

Have you ever applied for a position with this company in the past?*

In addition to your work history, do you have any other qualifications that are relavant to the position for which you are applying? (CERTIFICATIONS/LICENSES) Please list*

EMPLOYMENT HISTORY: List all employment experience within the past 10 years, starting with the most recent/present employer, including U.S. Military Service. Describe in detail all work experience, including periods of unemployment. Resumes may not be substituted in lieu of completing the following information.

Name of Employer:*

Job Title:*

Address:*

Dates of Employment:*

Supervisor:*

Starting and Ending Salary*

Phone Number:*

Responsibilities:*

Reason for Leaving:*

Name of Employer:*

Job Title:*

Address:*

Dates of Employment:*

Supervisor:*

Starting and Ending Salary:*

Phone Number:*

Responsibilities:*

Reason for Leaving:*

PLEASE READ EACH PARAGRAPH CAREFULLY BEFORE SIGNING
I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drug use before being permitted to commence work with Company. I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with Company. I understand, where permissible under applicable state and local law, I may be subject to a pre-employment background check after receiving a conditional offer of employment to investigate my criminal background and other matters related to my suitability for employment.
INITIALS:*

I hereby certify that the information given by me is true in all respects. I authorize Company and its representatives to contact my prior employers and all others (with the exception of my current employer, only if I have marked "May we contact your present employer" on this application as "No") for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested.
INITIALS:*

I understand employment with Company is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.

If employed, I understand that as a condition of employment that I may be required to agree to and sign a non-solicitation, non-disclosure, and/or other similar agreements. I also agree to notify the organization during the pre-employment process of any non-solicitation, non-disclosure, and/or other similar agreements that I may have already signed with current and former employers.

I expressly understand and agree that, if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at-will, with or without cause, by either party (Company or me) without prior notice to the other, unless otherwise prohibited by law.

I understand that no representation, whether oral or written, by any representative or agent of Company, at any time, can constitute an implied or express contract of employment. I further understand no representative or agent of Company has the authority to enter into an agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other terms or condition of employment other than in a document signed by an authorized representative.

I understand that the technical processing and transmission of the application, including my personal information, may involve (a) transmissions over various networks, including the transfer of this information to the United States and/or other countries for storage, processing and use by Company, its affiliates, and their agents; and (b) changes to conform and adapt to technical requirements of connecting networks and devices. Accordingly, I agree to permit such parties to make such transmissions and changes, and hereby provide the necessary consent for the same.
INITIALS:*

State Specific Notices

Massachusetts Applicants: IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITIES.

Maryland Applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

I certify that all of the above information is true and complete, and I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination regardless of the time elapsed before discovery.

Note: An offer of employment is conditioned upon complying with Company's requirements including, but not limited to, signing a consent to conduct a background investigation.

I AGREE, AND IT IS MY INTENT, TO SIGN THIS EMPLOYMENT APPLICATION BY CHECKING THE "I ACCEPT" BOX BELOW AND BY ELECTRONICALLY SUBMITTING THIS DOCUMENT TO COMPANY, I UNDERSTAND THAT MY SIGNING AND SUBMITTING THIS DOCUMENT IN THIS FASHION IS THE LEGAL EQUIVALENT OF HAVING PLACED MY HANDWRITTEN SIGNATURE ON THE SUBMITTED DOCUMENT.*

Signature and Date*

Human Check*