Application for Employment

2 Kennedy Blvd.
East Brunswick, NJ 08816
732.777.2588

Position Applying For

Specific position for which you are applying:
Availability:	M T W Th F Sat Sun
Hours:	to
Desired Start Date:
Desired Salary:
Are you able to perform the essential functions of the position for which you are applying, with or without reasonable accommodations?	Yes No

Background Information

Are you legally eligible for employment in the U.S.? (Successful applicants must submit proof of employment eligibility within the first 3 days of employment)	Yes No
Have you ever been convicted of a crime that has not been sealed or expunged by a court? (Answering yes to this question will not necessarily result in rejection of your application.)	Yes No
If yes, state the conviction, location of the court, and specific violation

Personal Information

First Name
Last Name
Home Address

City
State
Zip
Daytime Phone
Evening Phone
E-mail Address *Required
Best time to reach you	am pm

Education

Choose highest grade completed:		7 8 9 10 11 12 14 16 18 18+
Name	City	State	Graduate	Degree	Years
High School			Yes No
College			Yes No
Other Training			Yes No

Employment History (complete for last 3 positions, even if information also on resume)

Dates	Employer Name	Address	Telephone

Position(s) Held	Supervisor's Name	Final Salary	Reason for Leaving	May we Contact?
				Yes No

Dates	Employer Name	Address	Telephone

Position(s) Held	Supervisor's Name	Final Salary	Reason for Leaving	May we Contact?
				Yes No

Dates	Employer Name	Address	Telephone

Position(s) Held	Supervisor's Name	Final Salary	Reason for Leaving	May we Contact?
				Yes No

Special Skills

Typing	wpm
Word Processing (list all programs you know)
Other Relevant Skills or Experience
List all language (other than English) you can speak, read, or write.
Language
	Speak Fluently Understand Read Write
Language
	Speak Fluently Understand Read Write

Phlebotomist (please answer the following questions)

Can you arrive at our Client facilities before 5:30 a.m. weekdays?	yes no
Are you a Certified Phlebotomist?	Yes No
Can you perform venipuncture on pediatric patients?	Yes No
How far are you willing to travel from your home?	miles
Do you have a valid driver's license?	yes no
Driver License Number
State
Do you have use of a car?	yes no
Auto Insurance Company
Policy Number
Expiration Date	(MM/YYYY)

Medical Technologist (please answer the following questions)

What laboratory equipment can you operate confidently (please be specific, e.g., Coulter, STKS)
Which technical area do you feel most confident?
How would you rate your skill levels on a scale of 1 - 5 (5 being the best)?
Technical	Clerical	Computer	Customer Service

Clerical/Administrative (please answer the following questions)

Have you billed Medicare Part B in your previous experience?	Yes No
Have you billed NJ Medicaid or Insurances in your previous experience?	Yes No
Are you familiar with ICD-9 coding?	Yes No
Are you comfortable with heavy telephone work?	yes no

References

Name	Address	Telephone	Relationship	How Long?

Resume

Please copy and paste your plain text resume below.

Certification and Authorization

By my signature below, I authorize the Company to contact and obtain information from all references, employers, educational institutions, and to otherwise verify the accuracy of the information contained in this application and on my resume. I hereby release from liability the Company and its representatives for seeking, gathering and using such information; and all other persons, corporations or organizations for providing such information.

I understand that the Company is an equal opportunity employer and does not discriminate on the basis of race, religion, age, sex, ancestry, national origin, marital status, veteran status, sexual orientation, handicap or disability in the selection of candidates for interview or hiring. I also understand that the Company will consider reasonable accommodations for any applicant or employee with a handicap or disability who requests a reasonable accommodation during the application/interview process or during employment.

By my signature below, I acknowledge and agree that any offer of employment will be made contingent on confirmation of my references and licensure, successful completion of all pre-employment medical testing, drug screening and criminal background check. I also understand that if hired, I will be required to provide proof of identity and legal work authorization.

By my signature below, I certify that all of my statements contained in this application, on my resume, and information and documents I provided or will provide in support of my application for employment (both orally and in writing) are accurate and true. I understand that if any statement or information is found to be false, it may be grounds for rejection of my application, withdrawal of an offer of employment,, or termination of employment.

I understand in accepting this position I am employed at will and I am entering a 90-day probationary period. At any time during that period or any extension thereof, my employment may be terminated without notice, if my performance does not meet company standards.

By my signature below, I agree that I fully understand the statements above and agree to be subject to them.

Signature

Date