Applicant name (Please give complete name)

Are you at least 18 years old?
Yes No

Home Phone

E-mail Address

Present Address (Include City, State, Zip Code

Previous Address (Include City, State, Zip Code

Current open position(s) for which you are applying

1) 2) 3)

Type of Position

Shift

Salary Requirement

Are you willing to travel? Yes No

Are you willing to relocate? Yes No

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours? Yes No

If overtime work is required periodically does this pose a problem for you? Yes No

Date Available for Work

Are you currently employed?
Yes No

Have you ever worked in a facility associated with Integrated Regional Laboratories?
Yes No

If yes, what facility?

Are you related to any other facility employee?
Yes No

How did you learn about this position?

Are you able to perform the essential, job related functions of the position of which you are applying for with or without accommodations?

Yes No

Describe any accommodations necessary:

Have you ever been convicted of a crime and/or released from confinement following a conviction of any criminal offense?Yes No

Arrest or charges that have been expunged need not be disclosed. If yes, give date, place and nature of each such charge.

1) 2) 3)

Are you presently charged with any violation of the law?Yes No

If yes, give date, place and nature of each such charge.

1) 2) 3)

Educational History

Type of School

Name of School

Check Last Year
Attended in School

Degree or Certificate

City, State

High School/
GED

9101112

Graduated/GED?
Yes No

College

1234

Graduated?
Yes No

College

1234

Graduated?
Yes No

Graduate School

1234

Graduated?
Yes No

Other

From (Year)     To (Year)

Other

From (Year)     To (Year)

List any professional licenses, registration you possess
(include drivers license, if applicable)

Clerical or other skills applicable to
the position for which you are applying.

Typing ( wpm)     PBX

Proficient in Software: (list all)

Business machines and/or equipment you can operate:

Other:

Company

Phone Number

Immediate Supervisor

Salary

Address

May we contact them?

Yes     No

Name While Employed

Job Title

Department

Other reference with this employer

Reason for Leaving

Nature of Duties

Company

Phone Number

Immediate Supervisor

Salary

Address

May we contact them?

Yes     No

Name While Employed

Job Title

Department

Other reference with this employer

Reason for Leaving

Nature of Duties

Company

Phone Number

Immediate Supervisor

Salary

Address

May we contact them?

Yes     No

Name While Employed

Job Title

Department

Other reference with this employer

Reason for Leaving

Nature of Duties

Company

Phone Number

Immediate Supervisor

Salary

Address

May we contact them?

Yes     No

Name While Employed

Job Title

Department

Other reference with this employer

Reason for Leaving

Nature of Duties

You may also paste your resume in the box below.

Professional References (Other than Relatives)
Give two references who have a good working knowledge of your work.

1) 

2) 

Please Review and Sign Where Indicated

In making application for employment:

- I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

- I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has ben requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

- I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES

- I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought in or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.

- Compliance with this facility's Substance Abuse Policy is a condition of employment. This facility requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with facility policy. Continued employment is also contingent upon compliance with the facility's Alcohol and Drug Abuse Policy.

- I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE. I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL THE MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.

Release:

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.

I have read and understand
these conditions of employment.

By clicking on "send," I hearby attach my signature to this employment application as evidence that I have agreed to the above.