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Employment Application
General Information
First Name* Please enter your first name.   Last Name* Please enter your last name.   M.I. Invalid Input
Street Address* Please enter your street address.
City* Please enter your city.    State* Please enter your state.   Zip* Please enter your zip code.
Phone* Please enter your phone number.    Email* Please enter your email address.
Position You are Applying For* Invalid Input
Are there any hours you cannot work?* Please select if there are any hours you are unavailable to work.
If yes, explain
Invalid Input
Do you require working papers? (under 18 years of age)* Please specify if you require working papers.
Date you are available to start working* Please enter the date you are available to start working.
Any relatives or friends working for us?* Please specify if you have any relatives or friends working for us.
If yes, give names and locations Invalid Input
Can you perform essential job functions with or without reasonable accommodations? Describe:* Required field.
Will you be able to provide proof of U.S. citizenship or permanent residency upon employment?*
Please specify if you are a U.S. Citizen.
Education
High School Name Invalid Input    Address Invalid Input
Grade Completed Invalid Input    Degree/Major Invalid Input
College Name Invalid Input    Address Invalid Input
Grade Completed Invalid Input    Degree/Major Invalid Input
Other Name Invalid Input    Address Invalid Input
Grade Completed Invalid Input    Degree/Major Invalid Input
Other Name Invalid Input    Address Invalid Input
Grade Completed Invalid Input    Degree/Major Invalid Input
Employment History (starting with most recent)
Employed from Invalid Input    To Invalid Input
Company Name Invalid Input    Address Invalid Input
Phone Invalid Input   Name & Position of Supervisor Invalid Input
Salary Start Invalid Input    Salary End Invalid Input
Your job title and duties Invalid Input
Reason for leaving Invalid Input
 
Employed from Invalid Input    To Invalid Input
Company Name Invalid Input    Address Invalid Input
Phone Invalid Input   Name & Position of Supervisor Invalid Input
Salary Start Invalid Input    Salary End Invalid Input
Your job title and dutiesInvalid Input
Reason for leavingInvalid Input
 
Employed from Invalid Input    To Invalid Input
Company Name Invalid Input    Address Invalid Input
Phone Invalid Input   Name & Position of Supervisor Invalid Input
Salary Start Invalid Input    Salary End Invalid Input
Your job title and duties Invalid Input
Reason for leaving Invalid Input
 
If currently employed, may we contact your employer for reference purposes? Invalid Input   
If yes, give name, position and telephone number of person to be contacted Invalid Input
1. I hereby declare that the information provided by me in this application is true, correct and complete to the best of my knowledge and that any misrepresentation or falsification of this information shall be considered cause for cancellation of this application and/or separation from LIA's service if I have been employed.

2. I authorize LIA to investigate and check any of the foregoing data and references.

3. I agree to conform to the policies and procedures of LIA and I understand that work schedules are subject to change and that overtime may be required.

4. I understand that just as I am free to resign at any time, LIA reserves the right to terminate my employment at any time, for any lawful reason, with or without cause and without prior notice. I understand that no representative of LIA has the authority to make any statement to the contrary.



Patient Compliments

I've always been impressed how friendly and efficient Larchmont Imaging is!!


Everyone was so caring - only place I go and I always recommend it to others


Every visit here has been wonderful, comfortable and pleasant - staff is phenomenal. Thank you so much for the great service

Was very pleased that I called for appointment and was seen within the hour. Staff was extremely friendly and helpful.


I have always been treated professionally by Larchmont, but my experience last week was extraordinary! Your technicians were caring and awesome, and the doctor went above and beyond. Thank you so much! 

 

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