Full Time Medical Lab Technician/Medical Lab Scientist

Applicant Information

Last Name *

First Name *

Middle Name

Application Date *

Street Address *

City *

State *

Zip *

Email *

Home Phone

Cell Phone

What job are you applying for? *

Referred By

Military History

Are you a U.S. Military Veteran? *

Yes
No

What Branch?

Start Date of Service

End Date of Service

Rank at Discharge

Type of Discharge

If other than an honorable discharge, please explain:

If hired, can you submit proof of your legal right to work in the U.S.? *

Yes
No

Are you at least 18 years of age? *

Yes
No

Have you ever worked for this Hospital? *

Yes
No

If under 18, do you have a work permit?

Yes
No

When did you last work for this hospital?

Are you willing to take a physical exam and drug test upon a conditional offer of employment? *

Yes
No

Available Date To Start *

Do you have a valid driver's license? *

Yes
No

Will you respect a tobacco-free workplace? *

Yes
No

Are you presently charged with, or have you ever plead guilty, no contest, been given deferred adjudication, or been found guilty of a felony or misdemeanor? *

Yes
No

NOTE: Motor vehicle citations occurring more than five years ago need not be referenced. Conviction of a felony or misdemeanor will not automatically bar employment.

If you are presently charged with, or have ever plead guilty, no contest, been given deferred adjudication, or been found guilty of a felony or misdemeanor, please explain.

Education

High School

High School Name

Years Completed

City

State

Major or Course(s)

Graduated?

Diploma
GED
Did Not Graduate

Vocational or Trade School

Vocational or Trade School Name

Years Completed

City

State

Major or Course(s)

Degree

College

College Name

Years Completed

City

State

Major or Course(s)

Degree

Graduate School

School Name

Years Completed

City

State

Major or Course(s)

Degree

Skills, Qualifications, and Licenses

Skills, Qualifications, or Specialized Training

If you have a license, please list it below with the license information.

Type of License

License Number

Other License Type

Do you have another license that you would like to provide? *

Yes
No

Type of License

License Number

Other License Type

Previous Employment

Begin with your most recent employment.

Company Name

Type of Business

Start Date

End Date

Supervisor's Name

Phone

Job Title

Salary

Reason for Leaving

Still Working Here?

Yes
No

Responsibilities

Company Name

Type of Business

Start Date

End Date

Supervisor's Name

Phone

Job Title

Salary

Reason for Leaving

Responsibilities

Company Name

Type of Business

Start Date

End Date

Supervisor's Name

Phone

Job Title

Salary

Reason for Leaving

Responsibilities

May we contact the employer(s) listed above? *

Yes
No

Please indicate which employers we are not allowed to contact and the reason why.

References

List persons known at least five years and are not friends or relatives.

Last Name *

First Name *

City *

State

Phone *

Relationship *

Last Name *

First Name *

City *

State

Phone *

Relationship *

Last Name *

First Name *

City *

State

Phone *

Relationship *

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Applicant Certification Agreement

1. I certify that all of the information given by me on this application or in supplemental form is true, correct, and complete to the best of my knowledge. I further understand that false or misleading statements or consequential omissions of any kind of this application or supplemental forms are sufficient cause for my not being hired or my dismissal if I am hired.

2. I authorize and release the Hospital or its agents to contact, obtain, and verify information in this application from previous employers, educational institutions, and references. I authorize and release those organizations and individuals to provide and release information sought by the Hospital or its agents.

3. I understand that the Hospital is an equal employment opportunity employer, including that it is the policy of the Hospital not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of the individual’s need for reasonable accommodation pursuant to the Americans with Disabilities Act, as amended. I understand and agree that I should report any violation of the Hospital’s policies on equal employment opportunity and its policies prohibiting discrimination, harassment, and retaliation. If hired, I understand and agree I will comply with those policies and all applicable federal, state, or local law.

4. I agree that if employed, employment with the Hospital is for no definite duration and may be terminated at will by either the Hospital or me. The Employee Handbook or other policies or procedures of the Hospital are not a contract and cannot create a contract of employment for any definite duration. I agree and understand that only the Chief Executive Office of the Hospital has the authority to establish a contract of employment with me, and that any such contract must be in writing, designated as an employment contract, and signed by both parties.

5. This certified that this application was completed by me and that all entries on it and information in it are true, correct and complete, to the best of my knowledge.

Signature *

Applicant Information

Military History

Employment Questions

Education

High School

Vocational or Trade School

College

Graduate School

Skills, Qualifications, and Licenses

Previous Employment

References