ESC Lab Sciences -- Employment Application

Personal Information (Fields marked with an * are required)

*First Name :**	Middle:	*Last Name :**
Street Address:		Street Address2:
City:	State:	Zip:
*Email :**
Driver's License Number:	Driver's License State:
Have you ever been bonded?YesNo Answering "yes" to the following question does not mean you are automatically barred from employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?YesNo If yes, please provide date and details:

*Home Phone :** () -	Cell Phone: () -
May we contact you at home/cell? YesNo If yes, best time to call:
Work Phone: () - ext
May we contact you at work? YesNo If yes, best time to call:
Upload Resume:

Employment Opportunity (Fields marked with an * are required)

Desired Position * :

Are you legally eligible for employment in this country?
YesNo

How did you here about ESC?

Have you ever been employed at ESC before?
YesNo
If yes, please enter dates:
from

to

Have you ever submitted an application here before?
YesNo
If yes, please enter date applied:

Position Applied for:

Education History

Starting with your most recent school attended, provide the following information. You must provide at least 1 school.

School (Include City & State)	Years Completed	Completed	GPA	Major/Minor
		Describe
		Describe
		Describe
		Describe

Summarize any special training, instrumentation, skills, licenses and/or certificates related to the position for which you are applying.

Employment History

Starting with your most recent employer. Please be sure to explain any gaps in employment. All fields are required for each employer.
Never been employed

Employer:

Phone:
() -

Street Address

City

State:

Job Title:

Supervisor:

Supervisor Title:

May we contact for reference?
YesNoLater

Why Did You Leave?

Dates Employed:
from:

to:

(leave 'to' blank if still employed here)
Please explain any gaps in employment, other than those due to personal illness, injury, or disability

Starting Pay:
$Salary Hourly

Ending Pay:
$Salary Hourly

Summary of Responsibilities:

Employer:

Phone:
() -

Street Address

City

State:

Starting/Ending Job Title:

Supervisor:

Supervisor Title:

May we contact for reference?
YesNoLater

Why Did You Leave?

Dates Employed:
from:

to:

(leave blank if still employed here)
Please explain any gaps in employment, other than those due to personal illness, injury, or disability

Starting Pay:
$Salary Hourly

Ending Pay:
$Salary Hourly

Summary of Responsibilities:

Employer:

Phone:
() -

Street Address

City

State:

Starting/Ending Job Title:

Supervisor:

Supervisor Title:

May we contact for reference?
YesNoLater

Why Did You Leave?

Dates Employed:
from:

to:

(leave blank if still employed here)
Please explain any gaps in employment, other than those due to personal illness, injury, or disability

Starting Pay:
$Salary Hourly

Ending Pay:
$Salary Hourly

Summary of Responsibilities:

References

List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you. All fields are required.

Name	Title	Relationship To You	Phone	Number of Years Known
			() -
			() -
			() -

Affirmative Action

We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is strictly voluntary. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Gender:DeclineMaleFemale

Please select one of the following Equal Employment Opportunity Identification Groups:

Applicant Statement (Fields marked with an * are required)

1.  I certify that all information I have provided in order to apply for and secure work with ESC is true, complete and correct.

2.  I understand that ESC does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.

3.  I expressly authorize, without reservation that ESC, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I herby waive any and all rights and claims I may have regarding the employer, its agents, employees or representative, for seeking gathering and using truthful and no-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

4.  I understand that this application remains current for only 30 days. A the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

5.  I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

6.  If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor representative of the employer is authorized to make any assurance to the contrary and that no implied oral or written agreements contrary to the foregoing expressed language are valid unless they are in writing and signed by Environmental Science Corporation's president.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Full Name*:

Date*:

Email*: