Rad Tech

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Graduation Date *

MM

DD

YYYY

Are you certified by the ARRT in Radiography? *

Yes

No

Are you legally authorized to work in the United States? *

Yes

No

Have you ever been investigated for abuse, neglect, or domestic violence? *

Yes

No

Have you been convicted of any criminal or driving offense(s) other than a minor traffic violation? *

Yes

No

Do you have a valid driver's license? *

Yes

No

*

I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed. I understand that all offers of employment are conditioned upon my providing satisfactory documentary proof of my identity and legal right to live and work in the United States.

Yes

Signature Name *

First Name

Last Name

Signature Date *

MM

DD

YYYY