Application for Employment

Cardiodiagnostics is an equal opportunity employer.

All statements made by applicants for employment on this application form will be checked for accuracy. We offer equal employment opportunities to all persons without regard to race, color, religion, age, marital or veteran's status, sex, national origin, disability, or any other legally protected status.

Please note that fields denoted in RED are REQUIRED!

ALL INFORMATION ENTERED ON THIS APPLICATION IS ENCRYPTED AND SUBMITTED SECURELY.

Personal Information

Today's Date: Social Security Number:
Name:,

Current Address
Address:
 
City:    
State: ZipCode:  

Previous Address (if at current address less than 3 years)
Address:    
     
City:    
State: ZipCode:

Your Email Address:

Home or Nearest Phone:

Cell Phone:

(At least one phone number above is required. Both are preferred to allow us a better chance of reaching you if we need to do so. If you do not have either a home or cellular phone number, you may leave that field blank or unchanged.)

Please answer the following questions:

Q1: Who referred you to or how did you learn about Cardiodiagnostics?

Q2: Are you 18 years of age or older? Yes No Required Field

Q3: Have you used any names or social security numbers other than what you have listed above? Yes No Required Field

If yes, please list them below:

Q4: Have you ever pled guilty or nolo contendere to a criminal charge or been convicted of a crime (other than a minor traffic infraction)? Yes No Required Field

If yes, state the nature of the crime of which you plead guilty or nolo contendere or were convicted. Also provide the name of the court (list state or federal court), date, location of the court, and the place where the offense occurred. Also provide the name used by you in the court. Required Field

Q5:Have you ever been involuntarily separated from or been asked to resign from a previous job you held? Yes No Required Field

Q6: Have you ever been given the option of resigning or being involuntarily separated? Yes No Required Field

If you answered yes to either of the two previous questions, please identify the name and address of the employer and the reasons why you were asked to resign, given the option of resigning, or being involuntarily separated or involuntarily separated.

Q7: Are you employed now? Yes No Required Field

Q8: Why do you desire to make a change in your employment? Required Field

Q9: Have you ever been in a position of trust (handling money or confidential material) Yes No Required Field
If so, please state the name and address of such an employer and the dates you were employed therein.

Q10: Do you have the legal right to work and remain in the United States? Yes No Required Field
If not, why not?

Q11: Do you own your own car? Yes Required Field

If yes, please provide the following:

Auto Make Model Year

Q12: Do you currently have a valid driver's license? Yes No Required Field

If so, what type of driver's license? Standard Chauffeur's Commercial (Please check only one type.)

In what state are you licensed to drive?
License Number:

Q13: Do you have any relative(s) employed by Cardiodiagnostics? Required Field

Employment Desired

Position desired Position:

When would you be available to work? Date You Can Start:
-or-
Explain your availability:

Are you willing to work evenings? Yes No Required Field

Are you willing to work Saturdays? Yes No Required Field

Please indicate the type(s) of employment you are interested in below: Required Field
Full-time Part-time Temporary

If Part-time, what days and hours? Days: (Use CTRL+click to select multiple days)
Hours: from to

Have you ever applied to this company before? Yes No Required Field

Have you ever worked for this company before? Yes No Required Field

If so, please tell us when: Required Field

Do you have any professional registrations or certifications applicable to the position for which you are applying? Yes No Required Field

If so, please define your registrations or certifications below:

Registry Certification Name of the Registry or Certification Date Received Current Status and Number
Active Inactive Number:
Active Inactive Number:
Active Inactive Number:

Are there any other experiences, skills, or qualifications which you feel would especially qualify you for a position with us? If yes, please explain:

Education

Note: All applicable fields in this section are required.

Name and Address of School Mark Last Year Completed Did You Graduate? Subjects Studied and Degree(s) Received
Grammar School n/a n/a n/a
High School n/a Yes No
College 1 2 3 4 Yes No
Trade or Business Correspondence School 1 2 3 4 Yes No

 

General Information

Subjects of Special Study or Research Work or Internships:

Job Related Skills (for example, typing, computer experience, etc.):

Activities or Organizations (Civic, Athletic, etc.):

Prior Work History

Please list in order with current or last employer first. Account for your entire employment history and for any gaps in your employment.

1. Name and Address of Most Recent Employer:
Job Title and Duties:
Telephone Number: Starting Pay Rate:
Date Hired: Last Pay Rate:
Date Left: Immediate Supervisor:
Reason for Leaving:
May we contact this employer? Yes No
If no, why not?

 

2. Name and Address of NEXT Most Recent Employer:
Job Title and Duties:
Telephone Number: Starting Pay Rate:
Date Hired: Last Pay Rate:
Date Left: Immediate Supervisor:
Reason for Leaving:
May we contact this employer Yes No
If no, why not?

 

3. Name and Address of NEXT Most Recent Employer:
Job Title and Duties:
Telephone Number: Starting Pay Rate:
Date Hired: Last Pay Rate:
Date Left: Immediate Supervisor:
Reason for Leaving:
May we contact this employer? Yes No
If no, why not?

 

4. Name and Address of NEXT Most Recent Employer:
Job Title and Duties:
Telephone Number: Starting Pay Rate:
Date Hired: Last Pay Rate:
Date Left: Immediate Supervisor:
Reason for Leaving:
May we contact this employer? Yes No
If no, why not?

Have you ever received disciplinary action by one of the employers listed above? Yes No Required Field

If so, please explain when and the basis for the disciplinary action below:

Military Service

Have you ever served in the U.S. Armed Forces? Yes No Required Field

If yes, what branch?
Date Entered:
Date Discharged:
Type of discharge:

Please provide a copy of your Form DD214. Required Field
(See the bottom of this application for where and to whom to send this copy.)

List below duties and rank in the service and any special training that is relevant to the position for which you have applied:

References

List below three persons, not related to you, whom you have known for at least one year. Do not list relatives or former employers. All fields in this section are REQUIRED.

Name & Address Phone Relation to You Years Acquainted

 

Applicant's Statement

This section is REQUIRED. Failure to complete this section will result in voiding of this application.

Please be certain to read and follow the instructions highlighted in yellow below.

I affirmatively represent that all the information I have provided in this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for denial of my application and, if hired, dismissal from my employment. I therefore agree that, if I provide false information, conceal information, or cause or authorize anyone else to provide false information or to conceal information in connection with my application, Cardiodiagnostics will have no liability for not hiring me, or discharging me if the Company learns that such information is false or incomplete. I further authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Cardiodiagnostics and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Cardiodiagnostics.

<>Any offer of employment I may receive from Cardiodiagnostics is contingent upon my successful completion of the company's total pre-employment screening process, including the Company's receiving references that it considers satisfactory, and my satisfactory completion of any post-job offer pre-employment medical examination that the Company may require.

I understand that prior to being offered employment with Cardiodiagnostics I may be requested to take an employment examination. In the event I have a disability which will affect my ability to take the test, I will so inform Cardiodiagnostics prior to the administration of the test so that a reasonable accommodation can be made. Requested accommodations may include accessible testing sites, modified testing conditions, and accessible testing formats. Cardiodiagnostics reserves the right to require medical documentation concerning the need for the accommodation.

I understand that as a condition of employment, I may be required to undergo and successfully pass a test for alcohol and/or drugs. I also understand that, if employed, I may be required to submit to an alcohol or drug test at any time at the discretion of Cardiodiagnostics I hereby consent to such alcohol and drug testing at the request of Cardiodiagnostics.

In consideration of employment, I agree to conform to all of the rules and policies of the company. I fully understand that if I am hired, I will be an "at-will" employee, which means that my employment and compensation can be terminated, with or without cause or progressive discipline, and with or without notice, at any time, by Cardiodiagnostics. I understand I am employed for no specific length of time. I understand that no representative of the company, other than the President of Cardiodiagnostics, has any authority to enter in to any agreement with me for employment contrary to the foregoing. Furthermore, I understand and agree that any such agreement entered into by Cardiodiagnostics will not be enforceable unless it is in writing and signed by me and Cardiodiagnostics. I also understand and agree that no employee or representative of Cardiodiagnostics has the authority to or has made any verbal promises, commitments, or statements of any kind at any time which are legally binding on the Company.

Please open and print a copy of the Applicant's Statement by clicking here. The Statement must be signed and forwarded by FAX or mail to:

Cardiodiagnostics of Colorado Springs, Inc.
Attention: Veronica Maes

FAX: 719-444-3756

-- or --

1633 Medical Center Point, Suite 283
Colorado Springs, CO 80907

If you choose to print the entire application, please set your printer to print in LANDSCAPE orientation with left and right margins set at 0.5" to be certain all information in this electronic application is displayed on the printed copy.