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Shared Medical Services, Inc.
209 Limestone Pass
Cottage Grove, WI 53527
Tel: 608-839-9050
Fax: 608-839-8950

Name
Last Name
First Name
Middle Name
Other Last Name Used
Social Security Number --
Contact Information
Home Phone Number ()-
Alternative Phone Number ()-
May we contact you confidentially at your alternative number?
E-mail
Date Available To Start
Are you currently under an employment contract?
Are you eligible to work in the U.S.?
If work or educational experience was obtained under another name, please indicate the name
Dates the name was used From:  
  To:       
Have you ever been convicted of a crime other than a traffic violation?
WILL BE CONSIDERED ONLY AS RELATED TO POSITION SOUGHT
If yes, please explain
We have to be prepared to staff our scanners 7 days a week, 24 hours a day. Is there any reason you would not be able to work if your schedule required early morning, evening, or weekend hours?
If yes, please explain
Are you willing to relocate?
Any restrictions?
What is your location preference?
FIRST CHOICE

SECOND CHOICE
Do you have any interest in obtaining a Class "A" Commercial Driver's License?
Describe any factors or experiences that you believe qualify you for the position you seek or which make you a particularly desirable applicant
What are your salary expectations?
How did you find out about the job?  Newspaper 
   Reference 
   Other 
Residences

Please list all addresses where you have lived in the last three (3) years.

Please list most recent or present address first.
Current From  
  To       
Address
Address 2
City
State
Zip
Previous From   
  To        
Address
Address 2
City
State
Zip
Previous From   
  To        
Address
Address 2
City
State
Zip
Education
High School Name
Address
City
State
Zip
GPA
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
School Name
Address
City
State
Zip
GPA
Degree
Degree
What courses did you like most and why?
What courses did you like the least and why?
Describe any other educational or training programs you have completed that you believe are relevant to the position you seek
Foreign Language
I am able to speak
I am able to speak
Employment History

Please provide information on all employment for the most recent three (3) years.

Please list most recent or present employment first.
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From:  
  To:       
Type of Business
Position
Immediate Supervisor
Ending Compensation $ 
Briefly describe your duties and responsibilities
Reason(s) for Leaving
May we contact this employer?
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From  
  To       
Type of Business
Position
Immediate Supervisor
Ending Compensation $ 
Briefly describe your duties and responsibilities
Reason(s) for Leaving
Employer Name
Address
City
State
Zip
Telephone Number ()-
Dates of Employment From  
  To       
Type of Business
Position
Immediate Supervisor
Ending Compensation $ 
Briefly describe your duties and responsibilities
Reason(s) for Leaving
Have you ever been discharged from any employment?
If yes, please explain
Safety Screening

Strong magnets are used in the Magnetic Resonance Imaging (MRI) scanning process. Any metal object on or inside the body may be affected by the magnet on the MRI scanner. Therefore, for safety purposes, it is important that potential employees are screened for objects, procedures, or implants that may put them in danger in an MRI environment. Please check any of the following objects, procedures, or implants that apply to you. Checking any of the boxes below does not necessarily disqualify you from employment with Shared Medical Services. Further evaluation with our SAFETY DEPARTMENT or MANAGEMENT STAFF will be required to determine your eligibility for employment.

Pacemaker — Internal Electrodes/Wires

Cardiac Defibrillator

Neurostimulator/Biostimulator

Aneurysm Clip(s)

Artificial Heart Valve

Prior Heart Surgery

Coil(s)/Filter(s)/Stent(s)

Shunt

Electrical/Mechanical/Magnetic Implant(s)

Implanted Drug Pump

Penile Implant

Prior Ear Surgery

Ear Implants (cochlear, stapes)

Hearing Aid(s)

Prior Eye Surgery

Artificial Eye or Eyelid Spring

Prior Metal in Eye(s)

Tissue Expanders (breast)

Radiation Seeds

Metal Fragments in Body

IV Access Port

Birth Control Implants

None

Work Related References
Name
Address
City
State
Zip
Telephone ()-
*Optional E-mail
Work Relationship
Name
Address
City
State
Zip
Telephone ()-
*Optional E-mail
Work Relationship
Name
Address
City
State
Zip
Telephone ()-
*Optional E-mail
Work Relationship
Name
Address
City
State
Zip
Telephone ()-
*Optional E-mail
Work Relationship

All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age, handicap, marital status, source of income, class, physical characteristics, sexual orientation, or political beliefs, as required by federal, state, or local laws. No information on this application will be used for the purpose of discrimination on the basis of any such protected category.

I certify that all of the information on this application is true, complete and correct to the best of my knowledge. I understand that any false or misleading statements made by me may result in the rejection of my application and/or, if employed, my immediate dismissal. In the event of rejection or dismissal, I agree that Northern Shared Medical Services, Inc., shall have no further obligation to me and I release the company from any claims I may have.

I understand that all information on this application is subject to verification. I authorize SMS to contact my former employers and all other persons or organizations referenced in this application (or accompanying resume) to verify my prior educational and work histories, criminal and driving records, or any other information provided on this application (or accompanying resume) and as disclosed during the interview process. I further authorize all persons or organizations listed on this application to provide SMS with any information requested. I release SMS and all persons or organizations providing information to SMS from all liability or legal claims arising out of such inquiry.

I agree to have a physical examination and drug screening prior to employment or in the future, if requested, at the expense of Northern Shared Medical Services, Inc.

I understand that any offer of employment is conditional on my ability to prove my identity and my right to work in the United States.

I understand and agree that if I am employed, my employment can be terminated with or without cause or reason by either party.

I also understand and agree that no one employed by the company has the authority to enter into any agreement, whether oral or written, to employ me on any other basis than is stated in the preceding paragraphs.

Today Date
 

We understand that the internet is a vulnerable means of communication and may be intercepted by unauthorized parties. An alternative means of submitting your application is to print this form and fax it to SMS at 608.839.8950. SMS is not responsible for any miss handling or interception of this application.