NGH Data Breach Press Release

Job Application: Lab Tech

Title: Lab Tech

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

Application for Employment

Name *
Home Phone
Cellular/Other *
E-mail Address *
Address
City/State/Zip
Shift Preferred *	1 2 3 4 Any Not Applicable
How were you referred to the company? *
Type of work desired *	Full-time Part-time Seasonal Temporary
On what date would you be available for work? *
Have you ever been employed here before? *	Yes No
If yes, give dates
Do you have a legal right to be employed in the USA? *	Yes No
If you are under 18, can you provide a work permit if required? *	Yes No N/A
DL#
State

Educational Background High School:

Name and location
Course of study
Did you graduate?	Yes No
Degree or Diploma

College:

Name and location
Course of study
Did you graduate?	Yes No
Degree or diploma

Graduate School:

Name and location
Course of study
Did you graduate?	Yes No
Degree or diploma

Vocational or other training:

Name and location
Course of study
Did you graduate?	Yes No
Degree or diploma

Continuing Education:

If any, list here
Special training or skills (languages, machine operation, etc.) that would benefit you in the job for which you are applying:

Employment Experience

1. Employer: Please list the most recent employer first.

Name of Employer
Contact: If you do not want us to contact an employer, mark accordingly.	Yes No
Address
Position
Supervisor
E-mail
Phone
Dates Employed from (mm/yy) to (mm/yy)
Hourly rate/salary: (starting and final)
Reason for Leaving

2. Employer

Name of Employer
Contact: If you do not want us to contact an employer, mark accordingly.	Yes No
Address
Position
Supervisor
E-mail
Phone
Dates Employed: from (mm/yy) to (mm/yy)
Hourly rate/salary: starting and final
Reason for Leaving

3. Employer

Name of Employer
Contact: If you do not want us to contact an employer, mark accordingly.	Yes No
Address
Position
Supervisor
E-mail
Phone
Dates Employed: from (mm/yy) to (mm/yy)
Hourly rate/salary: starting and final
Reason for Leaving

4. Employer

Name of Employer
Contact: If you do not want us to contact an employer, mark accordingly.	Yes No
Address
Position
Supervisor
E-mail
Phone
Dates Employed: from (mm/yy) to (mm/yy)
Hourly rate/salary: starting and final
Reason for Leaving

Resume

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