Employment Verification

Name

Company Name

Employer Address

Start Date

Employer Phone Number

Supervisor's Name

Your Position / Title

List of Job Duties (Please select all that apply)
Magnetic Resonance Imaging (MRI) TechnologistRadiologic/ X-Ray TechnologistDiagnostic Medical Sonographer (DMS)Echocardiography/Noninvasive Cardiovascular SonographerCentral Supply TechSurgical TechnologistDialysis TechnologistPhlebotomy TechnicianMedical AssistingEKG Technician

Signature

My Electronic signature certifies all the information above as true and correct to the best of my knowledge. Part Time/Temporary Work Statement: My electronic signature above indicates my choice to seek or accept part time work. Part time work is defined as at least 20 hours per week for 5 weeks (35 calendar days)

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