Job Application: Regulatory Assistant

Title: Regulatory Assistant

Fields marked with an asterisk (*) must be filled out before submitting.

PERSONAL INFORMATION

FIRST NAME *
MIDDLE NAME
LAST NAME *
PHONE NUMBER *
EMAIL *
PRESENT ADDRESS (STREET, CITY, STATE, ZIP) *
PERMANENT ADDRESS (STREET, CITY, STATE, ZIP)
LEGALLY ELIGIBLE FOR WORK IN THE U.S. * YES
NO
ARE YOU OVER THE AGE OF 18 * YES
NO
If You Are Under The Age Of 18, Can You Furnish A Work Permit * YES
NO
REFERRED BY

EMPLOYMENT DESIRED

POSITION *
DATE YOU CAN START *
SALARY DESIRED
TYPE OF WORK YOU DESIRE FULL-TIME
PART-TIME
TEMPORARY
ARE YOU CURRENTLY EMPLOYED * YES
NO
IF YES, MAY WE CONTACT YOUR CURRENT EMPLOYER * YES
NO
HAVE YOU EVER APPLIED TO THIS COMPANY BEFORE YES
NO
IF YES, WHERE AND WHEN

EDUCATION

HIGH SCHOOL: PLEASE LIST THE NAME, LOCATION AND YEARS ATTENDED
DID YOU GRADUATE YES
NO
GED
COLLEGE: PLEASE LIST THE NAME, LOCATION AND YEARS ATTENDED
DID YOU GRADUATE YES
NO
IF YES, WHAT WAS YOUR DEGREE
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL: PLEASE LIST THE NAME, LOCATION AND YEARS ATTENDED
DID YOU GRADUATE YES
NO
*THE AGE DISCRIMINATION IN EMPLOYMENT ACT OF 1967 PROHIBITS DISCRIMINATION ON THE BASIS OF AGE WITH RESPECT TO INDIVIDUALS WHO ARE AT LEAST 40 BUT LESS THAN 70 YEARS OF AGE.

MILITARY

US MILITARY OR NAVAL SERVICE YES
NO
IF YES, WHAT BRANCH AND RANK
ARE YOU PRESENTLY IN THE NATIONAL GUARD OR RESERVES YES
NO
DESCRIBE ANY TRAINING RECEIVED RELEVANT TO THE POSITION FOR WHICH YOU ARE APPLYING

FORMER EMPLOYERS

LIST BELOW YOUR LAST FOUR EMPLOYERS, STARTING WITH LAST ONE FIRST. FOR EACH EMPLOYER PLEASE LIST THE NAME & LOCATION, SALARY, POSITION, YEARS EMPLOYED AND REASON FOR LEAVING
EMPLOYER #1 *
EMPLOYER #2 *
EMPLOYER #3 *
EMPLOYER #4 *

ADDITIONAL INFORMATION

THIS JOB REQUIRES FLUENT SPEAKING AND WRITING IN ENGLISH, CAN YOU MEET THIS REQUIREMENT * YES
NO
CAN YOU PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB APPLIED FOR (IF JOB DESCRIPTION PROVIDED) WITH OR WITHOUT REASONABLE ACCOMMODATIONS (I.E. SPECIAL EQUIPMENT, LIGHTING, ETC.) * YES
NO
THIS JOB MAY REQUIRE THE OPERATION OF A VEHICLE, DO YOU HAVE A CURRENT AND VALID NEBRASKA DRIVER LICENSE * YES
NO
HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN TRAFFIC VIOLATIONS * YES
NO
IF YES, PLEASE DESCRIBE (A CRIMINAL CONVICTION WILL NOT BE AN ABSOLUTE BAR TO EMPLOYMENT, BUT WILL ONLY BE CONSIDERED IN RELATION TO SPECIFIC JOB REQUIREMENTS)

REFERENCES

GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR. FOR EACH PERSON, PROVIDE FULL NAME, CONTACT INFORMATION, EMPLOYER AND YEARS KNOWN.
REFERENCE #1 *
REFERENCE #2 *
REFERENCE #3 *

RESUME

PLEASE ATTACH YOUR RESUME *
I CONSENT TO HAVING AMERICAN LABORATORIES, INC. CONTACT ANYONE THAT IT DEEMS APPROPRIATE TO INVESTIGATE ORVERIFY ANY INFORMATION I HAVE GIVEN OR TO DISCUSS MY BACKGROUND, PAST PERFORMANCE OR SUITABILITY FOR EMPLOYMENT. I FURTHER CONSENT TO BEIGN DISCUSSED BY ANY PERSON SO CONTACTED. I AUTHORIZE AMERICAN LABORATORIES, INC. TO RELEASE EMPLOYMENT INFORMATION TO PLACES WHERE I HAVE FILED AN EMPLOYMENT APPLICATION, WHETHER DURING OR AFTER MY EMPLOYMENT AT AMERICAN LABORATORIES, INC.
ELECTRONIC SIGNATURE *
DATE *

DISCLAIMER

*IF YOU HAVE ANY QUESTIONS REGARDING THE FOLLOWING STATEMENTS, PLEASE ASK THEM OF AN EMPLOYMENT INTERVIEWER BEFORE SIGNING.
THIS COMPANY DOES NOT DISCRIMINATE IN HIRING OR EMPLOYMENT ON THE BASIS OF RACE,COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS, CITIZENSHIP, PREGNANCY, MARITAL STATUS, ANCESTRY OR STATUS WITHIN ANY OTHER PROTECTED GROUP. NO QUESTIONS ON THIS APPLICATION ARE INTENDED TO BE USED FOR SUCH DISCRIMINATION.
THIS APPLICATION WILL BE ACTIVE FOR 60 DAYS. AFTER THAT PERIOD, IF YOU STILL WISH TO BE CONSIDERED, YOU MUST COMPLETE A NEW APPLICATION.
BY SIGNING YOUR NAME BELOW, YOU CERTIFY THAT ALL STATEMENTS MADE BY YOU ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF YOUR KNOWLEDGE AND THAT YOU UNDERSTAND THAT MISREPRESENTATIONS OR OMISSIONS MAY BE CAUSE FOR REJECTION, OR MAY BE CAUSE FOR SUBSEQUENT DISMISSAL IF YOU ARE HIRED.
BY SIGNING YOUR NAME BELOW, YOU UNDERSTAND THAT NOTHING CONTAINED IN THIS APPLICATION OR IN THE INTERVIEW PROCESS IS INTENDED TO CREATE AN EMPLOYMENT CONTRACT BETWEEN THE COMPANY AND YOU. SHOULD THIS APPLICATION RESULT IN YOUR EMPLOYMENT, YOU HAVE A RIGHT TO TERMINATE YOUR EMPLOYMENT AT ANY TIME AND FOR ANY REASON AND THE COMPANY RETAINS A SIMILAR RIGHT. YOU FURTHER UNDERSTAND THAT NO REPRESENTATIVE OF THE COMPANY OTHER THAN THE BUSINESS ADMINISTRATOR HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT WITH YOU FOR ANY SPECIFIED PERIOD OF TIME OR TO GUARANTEE SOME OTHER PERSONNEL MOVE OR BENEFIT. YOU FURTHER UNDERSTAND THAT THIS ENTIRE STATEMENT APPLIES TO THE PERIOD PRIOR TO OR AFTER YOU MAY BE EMPLOYED.
I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND EACH OF THE ABOVE STATEMENTS.
ELECTRONIC SIGNATURE
DATE