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Supplemental Questionnaire

Last Name
First Name


NOTE: Please ensure that you provide all work history within the Employment Experience section of the "Work" tab. A resume will not be accepted in place of Employment Experience section. Please make sure the following fields are complete and accurate:

  • Name of Employer
  • Type of Business (or Facility)
  • Your position title
  • Your average hours worked per week
  • Your start and stop dates of employment
  • Description of primary duties

Do you possess two years experience performing diagnostics imaging in an acute care or medical clinical setting?

Yes No

Identify your direct experience and demonstrated competency in the functional areas of either radiography, fluoroscopy or CT scanning.



Please provide your ARRT (American Registry of Radiologic Technologists) number below:


Please provide your certification number issued by the State of California Department of Health as a Radiologic Technologist below:


This position may require possession of certification as cardiovascular Interventional Technology (CIT), certification in CT scanning or other recognized specialty certificates, and/or a State of California Certificate in mammography.

Please identify which certifications that you possess and provide the certification number below: