Employment Application

We are an equal opportunity employer. We consider applicants for all positions whtiout regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or hadicap, or any other legally protected status

Attach Resume:
*Email:
How Did You Hear About Us?:
*Position Applied for:

Applicant Information

    
*First Name: *Last Name: MI:
Maiden Name:
*Address: Apartment/Unit #
*City *State
*Zip *Phone:
Have you ever filed an application with us before?    Yes     No   If yes, explain briefly:
*When can you work?  Full Time    Part Time    Shift Work    Temporary  
Are you currently employed?    Yes     No   May we contact your present employer?    Yes     No  
Are you currently on "lay-off" status and subject to recall?    Yes     No   Are you currently enrolled in school?    Yes     No  
*Date Available:

Do you use tobacco in any form?    Yes     No  
*Are you authorized to work in the United States of America?
Proof of citizenship or immigration status will be required upon employment.
   Yes    No If the position you are applying for requires you to drive a company vehicle, how many traffic violations or accidents have you had within the last three years?
Are you physically or otherwise unable to perform the duties of the job for which you are applying?    Yes    No If so, explain:
Are you able to lift 60 pounds to waist-height safely?    Yes     No   Can you relocate out of town?    Yes     No  
*Have you been convicted of a felony in the past 7 years?
Convicition will not necessarily disqualify an applicant from employment
 Yes     No If yes, explain briefly:

Education

High School:   Years Completed:
Graduate:    Yes     No  
College:   Years Completed:
Graduate:    Yes     No   Degree:
Graduate/Professional:   Years Completed:
Graduate:    Yes     No   Degree:
College Hours (Chemistry):   College Hours (Biology):
College Hours (Microbiology):  

Special Skills and Attributes

Describe any specialized training, apprenticeship, skills and extra-curricular activities:
Describe any honors you have received:
State any additional information you feel may be helpful to us in considering your application:

Employment Experience

Start with your last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap, or other protected status.
*Company Name: *Complete Address
(w/ City, State, Zip):
*Phone: *Supervisor:
*Job Title: *Responsibilities:
*Starting Salary: *Ending Salary:
*Start Date:
(mm/yyyy)
*End Date:
(mm/yyyy)
*Reason for Leaving: *May we contact your previous employer for a reference?  Yes    No




References

Give name, address, and telephone number of four references who are not related to you and are not previous employers.
*Name: *Phone Number:
*Address:
*Name: *Phone Number:
*Address:
*Name: *Phone Number:
*Address:
*Name: *Phone Number:
*Address:

Authorization and Consent for Release of Information

Please Read Carefully

This application for employment shall be considered active for ninety (90) days. Any applicant wishing to be considered for employment beyond this time period should re-apply.

I, the undersigned, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that, if I am employed, any false statements will be considered as cause for possible dismissal.

I authorize Ana-Lab Corp. and any of its agents/designated Company Personnel, to disclose orally and in writing the results of this verification process and/or interview to the designated authorized representative of this Company.

I have read and understood this release and consent, and I authorize the background verification. I authorize persons, schools, current and former employers, and other organizations and Agencies to provide Ana-Lab Corp. with all information that may be requested, and to conduct a verification of my motor vehicle records.

I do hereby agree to forever release and discharge Ana-Lab Corp. and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, and expenses, or any other charge or complaint filed with any agency arising from the retrieving and reporting of information.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization if of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I understand that I am required to abide by all rules and regulations of the employer.

Signature below verifies you have read the above notice and understand what it means.


Confidential Survey

TO ALL APPLICANTS: Qualified applicants are considered for employment, and employees are treated during employment, without regard to race, color, religion, sex, national origin, age, marital status, veterans’ status, or disability. However, government agencies require periodic reports on the sex, ethnicity, disability, and veteran status of applicants. This data is for statistical analysis with respect to the success of the Affirmative Action program.

This survey is kept in a confidential file and not part of your application for employment or personnel file, should you be hired. No information contained in this survey is used in any way to discriminate in any employment practice.

Submission of this information is voluntary.

First Name: Last Name: MI:
Date: Position Applied For:
Birth Date: Sex:  Male    Female  
Race/Ethnic Group (indicate only one)      White    Black    Hispanic    American Indian/Alaskan Native    Asian/Pacific Islander    Other  

Veteran Status:

The information supplied will be used only in support of veterans programs in accordance with the regulations implementing 38 U.S.C. 4212.
Check all that apply.


Vietnam Era Veteran
A person who served more than 180 days of active military, naval, or air service, any part of which was during the period of August 5, 1964, through May 7, 1975; and
i. Was discharged or released therefrom with other than dishonorable discharge, or
ii. Was discharged or released from active duty because of a service-connected disability.



Special Disabled Veteran
i. A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veteran Affairs for a disability.
a. Rated at 30 percent or more or
b. Rated at 10 or 20 percent in the case of a veteran who has been determined under section 1506 of Title 38, U.S.C. to have a serious employment disability, or
ii. A person who was discharged or released from active duty because of service-connected disability.


A person with a disability is one who (1) has a physical or mental impairment which substantially limits one or more of a person’s major life activities, (2) has a record of such impairment, or (3) is regarded as having such impairment. An individual with a disability is “substantially limited” if he/she is likely to experience difficulty in securing, retaining, or advancing in employment because of a disability. This information is used only in accordance with the Rehabilitation Act of 1973, as amended, and Title 41 CFR 60-741.

I wish to be considered under your affirmative action plan for applicants with disabilities.

Please state nature of disability:

This information is given on a voluntary basis.