Employmt App 1-2011

APPLICATION FOR EMPLOYMENT
Biotech Partners considers applicants for all positions without regard to race, color, religion, sex, ancestry, national origin, age, marital or veteran status, disability, sexual orientation or AIDS, the presence of a non-related medical condition or handicap, or any other legally protected status. Date: PERSONAL DATA Name: Present Address: Social Security No.:
How long have you lived in this state? Job applying for: How did you learn of this opening? If hired, on what date will you be available to start work?
Telephone No.:
Are you prevented from lawfully becoming employed in this county due to Visa or immigration status? Yes No Have you ever been convicted of a felony, excluding convictions that have been ordered sealed or expunged or statutorily eradicated? Yes No Indicate level of proficiency in the following computer programs: Windows: QuickBooks: MS Word: Access: MS Excel: MS PowerPoint:
To the best of your knowledge, do you have any physical limitations that would interfere with the performance of this job? Yes No
If yes, please explain:
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Type of School
EDUCATIONAL BACKGROUND Name of School Years Graduated Attended Yes No Yes No Yes No Yes No RECORD OF EMPLOYMENT
Major Subject
List your last position first. Account for all employment during the past ten years. List additional details on separate page, if necessary. Please also attach a copy of your resume.
Dates (mo/yr) From To Employer's Name and Address; and Supervisors Name and Phone Number Rate of Pay Start Finish Reason for Leaving
May we contact the employers listed above? Yes No If no, please indicate below which one(s) you do not wish us to contact.
Summarize special skills and qualifications acquired from employment or other experience:
Occasionally the form of an application makes it difficult for an individual to adequately summarize her/his complete background. To assist us, please attach a cover letter and summarize any additional information necessary to describe your full qualifications.
REFERENCES Please provide the names and contact information of at least two references who were not your immediate supervisors in previous jobs.
Name, Title, Company/Organization, Address and Phone Number
MILITARY SERVICE RECORD Have you ever served in the armed forces of the United States? Yes No If yes, which branch and what time period? SPECIAL NOTICE TO VIETNAM ERA VETERANS AND INDIVIDUALS WITH DISABILITIES Government contractors are subject to 38 USC 2012 of the Vietnam Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans of the Vietnam Era, and Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified physically or mentally disabled individuals. If you are a disabled veteran, or have a physical or mental handicap you are invited to volunteer this information which will be treated as confidential. Failure to provide this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified, please mark the appropriate box and sign below. Physically or Mentally Disabled Signed: Disabled Veteran Vietnam Era Veteran Date:
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY Name: Address: Relationship (e.g., spouse, significant other, friend): Daytime Phone No.
APPLICANT'S CERTIFICATION AND AGREEMENT I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge. If employed, I agree to abide by and observe all rules and regulations of Biotech Partners. I also understand that employment depends upon satisfactory replies from references. Any misrepresentation on this application is reason for immediate dismissal. The use of this form does not indicate that there are any positions open, and does not in any way obligate Biotech Partners. I give the education institution, business and personal references listed above my permission to give complete reference data to Biotech Partners. Signed: Date:
Thank you for your application and interest in employment with Biotech Partners. Opportunities for employment with Biotech Partners will be based entirely on merit.
/var/www/apps/conversion/tmp/scratch_3/129545155.doc

Employmt App 1-2011

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APPLICATION FOR EMPLOYMENT

If yes, please explain:

Name, Title, Company/Organization, Address and Phone Number

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