X-Ray Technician/Medical Assistant (AM Shift)

Personal Information

Full Name *

Address *

City, State, ZIP *

Phone Number *

Email *

Preferred Contact Method *

Phone

Email

Are you legally authorized to work in the U.S.? *

Are you at least 18 years of age? *

Position Details

Position Applying For: *

Employment Type *

Part-Time

Full-Time

Available Start Date *

Willing to rotate between urgent care, pharmacy, and front desk duties? *

Licensure & Certification

Radiologic Technologist/X-Ray License Number *

Issuing State *

License Expiration Date *

Medical Assistant Certification (if applicable)

CMA

RMA

CCMA

None

Issuing Organization

Expiration Date

Pharmacy Technician License or Trainee Registration

Yes

No

If yes, license number:

Expiration Date:

CPR/BLS Certification

Yes

No

Expiration Date:

Additional Certifications

Education

Institution *

Degree/Certificate *

Field of Study *

Year Completed *

Professional References

Provide two professional references (supervisors, instructors, or managers).

Name *

Title/Relationship *

Phone/Email *

Name *

Title/Relationship *

Phone/Email *

Professional Statement

Briefly describe why you would like to join University Urgent Care & Pharmacy and how your skills align with our mission of providing patient-centered, integrated care.

Applicant Certification

By submitting this application, I certify that the information provided is accurate and complete. I understand that any misrepresentation or omission may result in disqualification or termination if employed. I authorize verification of credentials and references provided.

Signature (Typed) *

Date *

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