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Personal Information

First Name Middle Initial Last Name

Street Address / Apartment Number

Street Address Line 2 (optional)

City State

Zip Code / Postal Code

$ per Hour per Year

Skills and Experience

Education

Work Experience

Employer 1 (required)

Street Address

Street Address Line 2 (optional)

City State/Province

Zip Code / Postal Code

to

$

$

Employer 2 (optional)

Street Address

Street Address Line 2 (optional)

City State/Province

Zip Code / Postal Code

to

$

$

Employer 3 (optional)

Street Address

Street Address Line 2 (optional)

City State/Province

Zip Code / Postal Code

to

$

$

Legal

Note that a conviction of a crime will not necessarily disqualify you for employment.

Authorization

I certify that I have read and understand all parts of this application and certify that I have truthfully and completely answered all questions. I understand that falsification of any of the information given herein or on any other employment form is grounds for immediate termination, regardless of when such falsifications may be discovered.

I authorize Image HealthCare and its representatives to investigate my education, employment experience, criminal conviction records, and all other aspects of my background relevant to my proposed employment, including all statements made by me in my application for employment. I release Image HealthCare and its representatives, as well as any person to whom such inquiry is directed, from any liability arising directly or indirectly from any such investigators.

Further, I understand that employment will be contingent upon successfully passing a pre-employment drug-screening test (except where prohibited). I understand my employment with Image HealthCare is for no definite length of time. I understand my employment may be terminated at any time, with or without cause, at the option of either Image HealthCare or myself. I understand that no employee or representative of Image HealthCare has any authority to make any agreement which is contrary to the foregoing. If accepted for employment, I agree to comply with all company policies and procedures and with all rules and regulations made known at the time of employment or any other time thereafter, and to perform all duties assigned to me to the best of my ability.

Image HealthCare is an equal opportunity employer. All applications for employment will be considered without regard to race, color, religion, sex, national origin, disability, age (over the age of 40), or veteran status. This application will remain active for 45 days. After that time, it must be renewed by the applicant if he/she wishes to be reconsidered for employment.