Last Revised: November 22, 2023

This form must be completed by all individuals requesting access to an irradiator or Gamma Knife.

The scope of the investigation must encompass at least the 7 years preceding the date of the background investigation or since the individual's eighteenth birthday, whichever is shorter. Lack of contact information will significantly increase the application processing time.

All fields with a red * are required fields. If your webform is not submitting, please confirm that all required fields are completed.

Applicant Information

Title
Applicant Information
Home Address
School 1 Information
School Type:
Was degree received?
Contact Name
Title
School 2 Information
School Type:
Was degree received?
Contact Name
Title

Education Information

School 3 Information
School Type:
Was degree received?
Contact Name
Title

Employment Information

Please complete this form in as much detail as possible. This section should contain all places of employment for the past seven years or since your 18th birthday. Please include military history.
 

Employer 1 Information
Contact Name
Title
Employer 2 Information
Contact Name
Title
Employer 3 Information
Contact Name
Title
Employer 4 Information
Contact Name
Title

Personal References

You must provide two personal references. References should be well acquainted with you and should be able to attest to your character.

Reference checks may not be conducted with any person who is known to be a close member of  your family, including but not limited to your spouse, parents, siblings, or children, or any individual who resides in your permanent household.

Reference 1
Title
Phone Type
Reference 2
Title
Phone Type
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