EPIC Employment Application
Notice to Applicants
We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services and programs is available to all persons. The objective of the company’s hiring procedures is to select the most qualified individual for the job. All applicants are encouraged to provide the company with information that will demonstrate the applicant's qualifications to perform the duties of the job for which the applicant is applying.


* Required Fields
Personal Background
*First Name:  
Middle Name:  
*Last Name:  
*E-mail Address:  
*Present Street Address:  
*City:  
*State:  
*Zipcode:  
Permanent Street Address:  
City:  
State:  
Zipcode:  
*Phone Number:  
Referred By:  
Position being applied for:  
*Date you can start:  
  FULL TIME  PART TIME
Are you willing to work overtime?   YES  NO
Specify Days:  
S M T W TH F S
Specify Hours:  
Salary Desired:  
Are you presently employed?   YES  NO
If so, may we inquire of your employer?   YES  NO
Have you ever applied to this company before?  
YES  NO
Where?  
When?  
If driving is a requirement of the job for which you are applying, do you have a valid driver's license?  
  YES  NO
Are you able, at the time of employment, to submit verification of your legal right to work in the U.S. (Verification and completion of Form I-9 must be submitted no later than three business days after date of hire.)
 
YES  NO
Have you ever been convicted of a felony which is substantially related to the functions or qualifications of the positions(s) for which you are applying? Note: This question does not apply to convictions which have been expunged or sealed: (A conviction record will not necessarily be a bar to employment.)
  YES  NO
If so, please describe fully the criminal convictions(s), listing the nature of the offense(s) and your rehabilitation since the convictions(s):  
Notice to applicants: State law permits employers to obtain a criminal record report from the Department of State Police of Convictions, other than those expunged as part of a juvenile record.
Educational Background
High School - Name and Location:  
Highest Grade Completed:   9  10  11  12/GED
College - Name and Location:  
Highest Grade Completed:   1  2  3  4
Major Area of Study:  
Trade, Business or Graduate School:  
Specialized technical skills (i.e., computer programming/language, software, equipment operation, special tools or machines):  
Work Experience
Please list below your last three employers, starting with your present or last place of employment. You may include any verifiable work performed on a volunteer basis, internship or military service.
Employer Name:  
Address:  
Phone Number:  
Employed From:  
To:  
Salary:  
Position:  
Name of Supervisor:  
Reason for Leaving:  
Employer Name:  
Address:  
Phone Number:  
Employed From:  
To:  
Salary:  
Position:  
Name of Supervisor:  
Reason for Leaving:  
Employer Name:  
Address:  
Phone Number:  
Employed From:  
To:  
Salary:  
Position:  
Name of Supervisor:  
Reason for Leaving:  
References
Please give the names of three additional work-related references whom we may call. Please do not list relatives. Individuals with no prior work experience may list school- or volunteer-related references.
1. Reference Name:  
    Position:  
    Company:  
    Phone Number:  
2. Reference Name:  
    Position:  
    Company:  
    Phone Number:  
3. Reference Name:  
    Position:  
    Company:  
    Phone Number:  
INVITATION TO SELF-IDENTIFY AND PRIVACY NOTIFICATION STATEMENT
EPIC Imaging is subject to Title VII of the Civil Rights Act of 1964, Section 503 of the Rehabilitation Act of 1973, Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974, Executive Order 11246, and Job for Veterans Act of 2002, which require government contractors to take Affirmative Action to employ and advance qualified women, minorities, veterans, and disabled individuals. The following information is requested to conduct statistical research and analyses and to prepare our Affirmative Action Programs in accordance with the laws and implementing regulations noted above. Completion of this form is strictly voluntary on your part and refusal to provide this information will not subject you to rejection of employment, discharge, or disciplinary treatment. Your cooperation will enable us to meet our compliance obligations under these laws. The information on this form will be treated in a confidential manner.

RACE/ETHNICITY DESIGNATION
Race/Ethnic designations as used by the Federal Government do not denote scientific definitions of anthropological origins. For the purposes of this survey, an employee may be included in the group(s) to which he or she appears to belong, identifies with, or is regarded in the community as belonging. In the event that you decline to self-identify your gender, race or ethnicity, the information will be determined by visual observation or other appropriate means.

RACE/ETHNIC INSTRUCTIONS: Please review the appropriate designation(s) below:

WHITE (NOT HISPANIC OR LATINO) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
BLACK OR AFRICAN AMERICAN (NOT HISPANIC OR LATINO) - A person having origins in any of the black racial groups of Africa.
HISPANIC OR LATINO - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
ASIAN (NOT HISPANIC OR LATINO) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
AMERICAN INDIAN OR ALASKA NATIVE (NOT HISPANIC OR LATINO) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER (NOT HISPANIC OR LATINO) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Ethnicity
Race
Gender
Applicant’s Statement
* I hereby authorize the EPIC Imaging to contact, obtain and verify the accuracy of the information contained in this application from all previous employers, educational institutions and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering and using such information to make employment decisions and all other persons or organizations for providing such information.

* I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered. I understand employment with EPIC Imaging, is an employment-at-will.

* If I am employed I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either the employer or I can terminate the relationship at will, with or without cause, at any time, so long as there is not violation of applicable federal or state law.

* I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.

* I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

* I understand that I will be required to take and successfully pass a Drug and Alcohol screening as a condition of employment. I understand that if I test positive for any alcohol or illegal substance, alter a testing sample or fail to provide a sample that the conditional offer of employment will be withdrawn and I will not be employed by EPIC.

* I understand this company will not tolerate any acts of violence or sexual harassment or discrimination of any kind. Such acts will lead to disciplinary action, up to and including immediate termination.

* I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.