Online Employment Application: Elite Medical Group Staffing: We provide diagnostic Imaging Services, Mobile MRI, CT and PET Scan Professionals

Professionals : Online Application

Please completed the application below. If you have questions, please contact us.

Elite Medical Group Staffing: Online Application

(Fields marked with * and areas in gray are all required)

Personal Information
*First Name		Middle Initial	*Last Name
*Home Phone	--	Cell Phone --	*Email

*Current Address
*City		*State	*ZIP
Permanent Address
City		State	ZIP
*Social Security Number:
Driver's License Number State *Expiration Date
*Shift Preference		Referred By
*Emergency Contact Name		*Relationship	*Phone # - -
*Date available for work

*Have you ever been convicted of a crime other than a minor traffic violation? (If you answered yes to one or both of the above questions, please send a separate email)	YES NO
If so, when, where and disposition?
*Have you ever been arrested for or charged with a crime involving a child?	YES NO
If so, when, where and disposition?
*Are you a US citizen?	YES NO
*Are you permitted to work in the US?	YES NO

Education
Name of School	City	State	Year	Degree
				(*required)

Certifications/License (Please list all credentials.)

Type	Certificate Number	Expiration Date
		(*required)

References

List names of two professional persons to whom you are not related and with whom you have worked in the
past. The period of acquaintance should be at least two years.

Reference #1
*Reference's Name		*Title
*Facility Name
*Phone	--	Fax	--
*Facility Address
*City		*State		*ZIP

Reference #2
Reference's Name		Title
Facility Name
Phone	--	Fax	--
Facility Address
City*		State		ZIP

* Employment History

List all previous work experience including military service record and any periods of unemployment. Begin with present position and work back to your first position. Attach resume, if necessary. If there were any periods of more than one month where you were self-employed or unemployed, list name and address of person(s) who can verify your activities during these periods.
(*At least provide one Employer)

From : Mo/Yr	To: Mo/Yr	Employer/Supervisor Address/Phone	Salary	Job Title/Description	Specific Reason Leaving

Copy and Paste Resume

I understand that Elite Medical Group Staffing will conduct necessary background searches in connection with my hiring. Depending on location lf assignment, searches may include but are not limited to work history, references, driving record, criminal background, social security verification, credit history, education, professional license, etc. Elite Medical Group Staffing will only disclose information necessary to contracting facilities. I authorize Elite Medical Group Staffing to conduct searches and to disclose information as necessary without liability for disclosure.

I certify that all statements made in this application are true, correct and complete, and made in good faith. I am signing this application under penalty of perjury, punishable by fine or imprisonment (US Code, Title 18, Section 1001).

I understand that nothing in this application, or in any prior or subsequent written or oral statement, creates a contract of employment or any rights in the nature of a contract. I agree and understand that if I am hired by Elite Medical Group Staffing, my employment will be at-will, for an indefinite period of time, and may be terminated at anytime, with or without cause or notice, at the option of EMG Staffing or myself. I understand that I have the right to end my employment at any time and that EMS Staffing retains the same right. I also understand that no one has the authority to enter into any contract, agreement or modification of the foregoing unless such contract, agreement or modification is in writing and signed by a representative of Elite Medical Group Staffing.

I understand that should Elite Medical Group Staffing hire me, it is my responsibility to make my availability known to EMG Staffing. Should I fail to do so EMG Staffing will assume that I am unavailable and not assign me an assignment.

I hereby additionally authorize the hospital/facility to which I am assigned to withhold from my terminal pay an amount equal to the cost of replacing all Company Property or uniforms issued by not returned or equal to any outstanding balance of services rendered. I understand that in order to be selected for an assignment, I must agree to submit to a pre-employment physical exam and test. These shall include, but not limited to, a physical exam, X-ray, tuberculosis skin test, urinalysis, and blood test to determine the presence of contagious diseases, chemical dependency, etc. I further understand that the results of the exam and tests shale be submitted to the employer for evaluation, and must satisfy the standards set by the employer before I can be considered for employment.

Electronic Signature


*Applicant Complete Name	*Enter Last 4 Digits of Social Security