Employment Application — Biomedical Equipment Technician
| School / Institution | Location (City, State) | Degree / Diploma | Field of Study | Year Graduated |
|---|---|---|---|---|
| Certification / License / Registration | Issuing Organization | Number (if applicable) | Expiration Date |
|---|---|---|---|
List equipment types, modalities, and manufacturers you have experience servicing (repair, PM, calibration):
| Equipment Type / Modality | Manufacturer(s) | Years Experience | Proficiency (Beginner / Intermediate / Advanced) |
|---|---|---|---|
Employment Application — Biomedical Equipment Technician — continued
List last three employers. Attach additional sheet if needed.
Employment Application — Biomedical Equipment Technician — continued
| Question | Answer | If Yes: |
|---|---|---|
| General Employment | ||
| Have you ever been employed by ERS Biomedical or any of its affiliated service centers? | □ Yes □ No | |
| Have you ever been terminated or asked to resign from any position? | □ Yes □ No | |
| Are you currently subject to a non-compete or non-solicitation agreement? | □ Yes □ No | |
| Have you ever had a professional license or certification revoked or suspended? | □ Yes □ No | |
| Are you able to perform the essential functions of this position with or without reasonable accommodation? | □ Yes □ No | |
| Driving Record | ||
| Do you currently hold a valid driver’s license? | □ Yes □ No | |
| Has your driver’s license ever been suspended or revoked? | □ Yes □ No | |
| Have you received any moving violations or citations in the past 3 years? | □ Yes □ No | |
| Have you been involved in any at-fault vehicle accidents in the past 3 years? | □ Yes □ No | |
| Do you have any DUI / DWI convictions on your driving record? | □ Yes □ No | |
| Criminal History | ||
| Have you ever been convicted of a felony? | □ Yes □ No | |
| Have you ever been convicted of a misdemeanor (excluding minor traffic violations)? | □ Yes □ No | |
| Do you have any charges pending against you? | □ Yes □ No | |
| Have you ever been convicted of theft, fraud, or a crime involving dishonesty? | □ Yes □ No | |
Note: A conviction will not necessarily disqualify you from employment. Factors such as the nature of the offense, time elapsed, and the requirements of the position will be considered.
I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may result in disqualification from consideration or, if employed, termination. I authorize ERS Biomedical to contact former employers, references, educational institutions, and to obtain a consumer report including background and driving record checks. I understand that employment is contingent upon passing such checks and other pre-employment requirements as applicable.