RADIOLOGIC TECHNOLOGIST

PRN

Hours

8/12/14 Hour Shifts, Days/Nights/Weekends/Holidays

Experience, Knowledge, and Skill

Minimum of 1 year experience as a Radiologic Technologist with clinic rotation in a hospital or diagnostic imaging center required. CT experience required.

Specialized or Technical Education Required

Graduate of AMA approved school of Radiologic Technology or equivalent. Must possess certification from The American Registry of Radiologic Technology.

Physical Effort Required

Strength: Medium Push: Frequently Pull: Frequently Carry: Frequently Lift: Frequently Sit: Occasionally Stand: Constantly Walk:

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Personal Information

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First Name:Last Name:Email:Telephone Number:If necessary, the best time to call you at home is:

Street Address:City, State, Zip Code:Driver's License #

Referral Information

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Referral Source:Please name referral source:Have you ever been employed by Hood Memorial?

Please name any friends or relatives that work for Hood Memorial:Have you ever been fired or asked to resign from a job?If yes, explain and give dates

Placement Information

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First position applied for:Second position applied for:Positions applied for:What is your desired salary range or hourly rate of pay?Type of work schedule interested in:

Will you work overtime, weekends, or holidays if required?If no, please explain:Are you legally eligible for employment in the country?Date available for work:

Education

High School

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Name of high school:Grade completed:

Graduated?

College

Name of college:Grade completed:Major or minor fields of study:

Graduated?Year:Type of diploma or degree:

Graduate School

Name of graduate school:Field of study:

Graduated?Year:

Vocational School/ Other

Name of vocational school / other:Major and minor field of study:Graduated:

Year:Type of diploma or degree:Other notable education:

Certifications / Licenses

License 1

License Description:License Number:State of issue:

Date issued:Expiration date:

License 2

License Description:License Number:State of issue:

Date issued:Expiration date:

License 3

License Description:License Number:State of issue:

Date issued:Expiration date:

License 4

License Description:License Number:State of issue:

Date issued:Expiration date:

If you are licensed, has your license ever been suspended or revoked or are you currently involved in any proceeding that could affect your license or certification?

If yes, please give date, location and disposition of your case:

Skills & Qualifications

Check each item in which you have training:If typing, how many words per minute?If other, please describe:Please use the space below for any additional information necessary to describe your full qualifications ( specialty areas such as ICU, OBGYN, special equipment or computer programs)

Do you speak, read or write any language other than English?If yes, please describe:

Employment History

Current Employer

Current employer:Street Address:City, State, ZipPhone:SupervisorMay we contact for a reference?

Start Date:End Date:Duties:Base Earnings:Reason for leaving:

Previous Employer 1

Previous employer:Street Address:City, State, ZipPhone:SupervisorMay we contact for a reference?

Start Date:End Date:Duties:Base Earnings:Reason for leaving:

Previous Employer 2

Previous employer:Street Address:City, State, ZipPhone:SupervisorMay we contact for a reference?

Start Date:End Date:Duties:Base Earnings:Reason for leaving:

References

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Reference 1

Name:Title:Phone:

Relationship to you:Number of years known:

Reference 2

Name:Title:Phone:

Relationship to you:Number of years known:

Reference 3

Name:Title:Phone:

Relationship to you:Number of years known:

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