Nebraska LabLinc

POSITION INFORMATION

Position(s) Applied For
Date Available
Are you applying for: (select one) Full-timePart-time		If part time, days and hours available:
Please mark the shift you prefer: (select one) Early Morning ? First ? Second ? Overnight ?

PERSONAL INFORMATION

First Name

M.I.

Last Name

Address

City

State

Zip

Primary Phone

Is it okay to leave a message?

Secondary Phone

Is it okay to leave a message?

Have you been employed with us before?

If yes, give dates:

Have you ever been convicted of a criminal offense, other than a minor traffic violation?

If yes, please give details including dates, charges, and dispositions:

Do you have relatives working for Pathology Medical Services or Nebraska LabLinc?

Name

Relationship

Location

How did you hear about our Company and our current openings?

Please list any professional, trade, business, or civic activities and offices held (exclude those which indicate race, color, religion, sex, or national origin). If applicable, please list ASCP registry number and/or accreditations.

Are you legally authorized to work in the United States? (Proof of eligibility to work in the U.S. will be required upon employment.)

EMPLOYMENT HISTORY (List below the last three employers, starting with the most recent one first)

Are you currently employed?

YesNo

What are your salary requirements?

1) Company Name (Current or Most Recent)	Position Held
Company Address	City	State	Zip
Phone Number	Supervisor's Name
Dates of Employment	Salary at Start	Leaving
Job responsibilities (characters left: 1000)
Reason for leaving

2) Company Name	Position Held
Company Address	City	State	Zip
Phone Number	Supervisor's Name
Dates of Employment	Salary at Start	Leaving
Job responsibilities (characters left: 1000)
Reason for leaving

3) Company Name	Position Held
Company Address	City	State	Zip
Phone Number	Supervisor's Name
Dates of Employment	Salary at Start	Leaving
Job responsibilities (characters left: 1000)
Reason for leaving

EDUCATION

High School or GED	City	State

College		City	State
Major		Date Started	Date Finished
Graduated?	Choose One	Degree

College		City	State
Major		Date Started	Date Finished
Graduated?	Choose One	Degree

Graduate School		City	State
Major		Date Started	Date Finished
Graduated?	Choose One	Degree

Other		City	State
Major		Date Started	Date Finished
Graduated?	Choose One	Degree

FILE UPLOAD

Please upload any relevant documents including résumé, cover letter, list of references, and letters of recommendation. Include a description of each document.
File Description

File Description

File Description

File Description

File Description

In consideration of my employment, I agree to conform to the policies and procedures of the company. I understand that in accepting this application, the company is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause and with or without notice at any time.

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application or omission of fact on either this application or during the pre-employment process will result in my application being rejected, or, if I am hired, in my employment being terminated.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. In addition, I authorize and request each former employer, school or individual, except to answer any questions that may be asked and will hold such persons harmless for giving factual information within their knowledge or records.

Please check this box if you agree to the above statements.