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Application Shady Grove Radiology

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					                          SHADY GROVE RADIOLOGICAL CONSULTANTS, P.A.
                                         20410 Observation Drive, Suite # 104
                                            Germantown, Maryland 20876
                                        Phone (301) 948-5700 Fax (301) 212-4225
                                        APPLICATION FOR EMPLOYMENT

Date:__________________________________

IT IS THE POLICY OF SHADY GROVE RADIOLOGICAL CONSULTANTS, P.A. TO OFFER EQUAL EMPLOYMENT
OPPORTUNITIES TO ALL QUALIFIED APPLICANTS AND EMPLOYEES WITHOUT REGARD TO RACE, COLOR,
AGE, RELIGION, SEX, MARITAL STATUS, SEXUAL PREFERENCE, GENETIC STATUS, DISABILITY, NATIONAL
ORIGIN, VETERAN STATUS, OR ANY OTHER PROTECTED CHARACTERISTIC. THIS POLICY APPLIES TO ALL
AREAS OF EMPLOYMENT, INCLUDING RECRUITMENT, HIRING, TRAINING AND DEVELOPMENT,
PROMOTION, TRANSFER, TERMINATION, LAYOFF, COMPENSATION, BENEFITS, AND OTHER TERMS,
CONDITIONS AND PRIVILGES OF EMPLOYMENT.

APPLICANTS ARE ENCOURAGED TO REQUEST ANY NEEDED ACCOMODATIONS TO PARTICIPATE IN THE
APPLICATION PROCESS.


                                                     PERSONAL DATA

Name:


                   Last                          First                         Middle

Current
Address:

                   Number                        Street                                  City/State/Zip


Home Telephone: _________________Cellular Telephone: _________________ Email address:_________________________

Social Security Number: ________________________           If under 18 years of age, please state your age: _______________

Are you legally authorized to work in the United States on a permanent basis? Yes _________ No _____________

If the answer is “no”, can you certify that if offered employment you can produce documents to establish your identity and that
you are legally authorized to work in the U.S.: Yes ________________ No___________________


                                                 EMPLOYMENT DESIRED


Position Desired:______________________________ □Full-time □Part-time            Referred by:___________________________


Minimum acceptable hourly or yearly rate of pay? __________________________


Date available to start: ______________________________________________


Have you ever previously applied to or worked for Shady Grove Radiological Consultants, P.A.? Yes ___ No ___

If so, please provide date and position: _____________________________________________________________




                                                                1
                                                    EDUCATION
                                       Name & Location                               Graduated              Still
                                          Of School         Major Course              Degree             Attending
HIGH SCHOOL

COLLEGE

GRADUATE SCHOOL

TRADE/BUSINESS OR
CORRESPNDENCE SCHOOL
OTHER

                                             U.S. MILITARY EXPERIENCE
Have you ever served in the U.S. Armed Forces?     Yes _________ No ___________ If yes, what branch?

Dates of Duty:       From: ____________________     To: ______________________     Rank at Separation: ____________

Briefly describe your duties:______________________________________________________________________________


LIST BELOW YOUR FORMER EMPLOYERS BEGINNING WITH YOUR PRESENT EMPLOYER - NOTE ANY
PERIODS OF UNEMPLOYMENT
EMPLOYER                            EMPLOYED                  JOB DESCRIPTION
Type of Business           From:

Address                                 To:

Phone

Position                                                SALARY

Name of Supv. & Title                   Starting:

Reason for leaving                      Ending:


EMPLOYER                                              EMPLOYED                           JOB DESCRIPTION
Type of Business                        From:

Address                                 To:

Phone

Position                                                SALARY

Name of Supv. & Title                   Starting:

Reason for Leaving                      Ending:


EMPLOYER                                              EMPLOYED                           JOB DESCRIPTION
Type of Business                        From:

Address                                 To:

Phone

Position                                                SALARY

Name of Supv. & Title                   Starting:

Reason for Leaving                      Ending:



                                                           2
REFERENCES: List 3 professional references, not relatives or friends, but preferably former supervisors or co-workers who
have personal knowledge of your character, experience and capabilities:

 NAME & OCCUPATION                         ADDRESS                   TELEPHONE NUMBER                      RELATIONSHIP




ADDITIONAL INFORMATION:

Please include any other information you think would be helpful to us in considering your for employment, such as additional
work experience, special skills (typing, computer knowledge, etc) activities, accomplishments, etc. (Exclude all information
indicative of age, age, race, religion, color, national origin, disability, genetic and marital status):




Have you ever been convicted of a felony or a misdemeanor? (You need not disclose the conviction if the record of the
conviction has been officially expunged) Yes _______ No ________ If yes, please describe: _________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

A RECORD OF CONVICTION DOES NOT NECESSARILY DISQUALIFY THE APPLICANT FROM EMPLOYMENT
CONSIDERATION, AND FACTS SUCH AS RECENCY AND REHABILITATION WILL BE CONSIDERED.

CERTIFICATION: I certify that all information on this application and any other material provided by me is true and complete
and understand that any misrepresentation of information or omissions may disqualify me from employment consideration and
will be considered justification for dismissal whenever discovered, if employed.

I hereby authorize Shady Grove Radiological Consultants, P.A. to check with all persons, educational institutions, employers, and
other organizations including, but not limited to those named herein (and accompanying resume, if any) regarding any
information provided herein, and hereby consent to their providing job related information about me.

I understand that if I am hired, I will be required to conform to each of the policies and procedures maintained by Shady Grove
Radiological Consultants, P.A. Further, I understand the Shady Grove Radiological Consultants, P.A. follows an “employment
at-will” policy, and that in the event I am hired, I or Shady Grove Radiological Consultants, P.A. terminate the employment
relationship at any time, for any reason, with or without prior notice, and that this “employment at-will” policy cannot be
changed unless the change is specifically authorized in writing by the President of Shady Grove Radiological Consultants, P.A. I
further understand that this application is not a contract of employment, or a contract with respect to the terms of employment.

A consumer credit report may be requested in connection with the application. Upon request, I shall be informed whether or not
such a consumer credit report was requested. If a report was requested, I shall be informed of the name and address of the
consumer credit reporting agency that furnished the report. Subsequent consumer credit reporting agency may be requested or
utilized in connection with an update, renewal or extension of the employment for which this application for which this
application is made. My signature on this application form, among other things, authorizes Shady Grove Radiological
Consultants, P.A. to obtain such a report or reports without further notice.

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION
OF EMPLOYMENT, PROPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN
INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO
VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT
EXCEEDING $100.00


                                       Applicant’s Signature ____________________________________________

                                       Applicant’s Printed Name __________________________________________

                                       Date: __________________________________________________________

                                                               3
                       DO NOT WRITE BELOW THIS LINE.FOR PERSONNEL USE ONLY



Interviewed By: ______________________________   2nd Interview By: ____________________________________

Position: ____________________________________   □ References checked:   □ Licenses/certifications verified:

Employment Date: ____________________________    Starting Salary: _____________________________________




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