APPLICATION FOR EMPLOYMENT

Name*

First NameMiddle InitialLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

City/State

Zip Code

Are you 18 years of age or older?*

YesNo

Years of Phlebotomy experience *

If hired, can you provide evidence of legal eligibility to work in the U.S.?*

Your availability for work:*

	Mon	Tue	Wed	Fri	Sat
From:
To:

Total hours per week you are available to work?*

Type of work your looking for*

Full TimePart TimePRN (As Needed)

Type of phlebotomy position you prefer:*

Mobile PhlebotomistIOP (In Office PhlebotomistOpen to both

Where in Arizona do you currently live?*

East ValleyWest ValleyOther

Do you have a working Centrifuge?*

YesNo

Do you have full coverage auto insurance?*

YesNo

Do you have a working computer & printer at home?*

YesNo

Do you have Wifi at home?*

YesNo

Did you Graduate from high school?*

YesNoGED

Did you Graduate from a accredited Phlebotomy or Medical Assistant?*

YesNo

List any job related skills or accomplishments, certifications

References*

	Name	How do you know them & for how long have you known them	Phone number
1)
2)
3)

Date you can begin work?*

Date

Upload Resume*

| certify that all of the information provided in this employment application are true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including a criminal background and drug screen. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date.

I authorize the investigation of any or all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I have read, understand, and agree to the above statements.

Signature*

Date*

Today's date

APPLICATION FOR EMPLOYMENT

CAREFULLY READ EACH STATEMENT BEFORE SIGNING AT THE BOTTOM