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Do you have the legal right to seek employment in the United States? * Yes No
Are you at least 18 years of age? * Yes No
I have read and understand Article 23-A *.
Are you vaccinated for COVID-19? * Yes No
Availability: * Part Time Full Time
Days and hours available: 1st shift 2nd shift 3rd shift Monday - Friday Weekend Rotations Holiday Rotation
Have you ever applied for employment at Laboratory Alliance of CNY before? Yes No
Were you ever employed here? * Yes No
Desired Rate of pay: $ / hour
Can you perform the essential duties of the position for which you are applying? * Yes No
If you have any questions as to what functions are applicable to the position for which you are applying, please ask the interviewer before you answer this question.
Starting with your most current employment, list all of your previous positions held. MUST complete the employment history below.
I have no previous work history.
From JanFebMarAprMayJunJulAugSepOctNovDec 19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 to JanFebMarAprMayJunJulAugSepOctNovDec 19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 *
From JanFebMarAprMayJunJulAugSepOctNovDec 19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 to JanFebMarAprMayJunJulAugSepOctNovDec 19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024
Select the last year of school completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Did You Graduate? * Yes No
If no, do you have a High School Equivalency Diploma (GED)? Yes No
Diploma? Yes No
Did You Graduate? Yes No
List 3 job references (include co-workers, managers, and supervisors).
All fields are required.
I agree that, if employed, that any kind of falsified statements or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I agree that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice.
I also grant permission for the authorities of Laboratory Alliance of Central New York, LLC to investigate any and all information and release said organization from any and all liabilities resulting from such investigation. This may include, but is not limited to, current or prior employment / educational references, verification of professional licensure, driver's license validity (MVR check), a criminal record check, and drug screening.
I also agree that as a condition of employment, in compliance with Federal regulations under the Center for Medicare / Medicaid Services (CMS) , Laboratory Alliance will verify that I am not included on any of the Federal lists of excluded persons including, but not limited to: the Office of Inspector General (OIG), the Office of Medicaid Inspector General (OMIG) and the Excluded Parties List System (EPLS). I agree that an inclusion on either or all of the above Federal lists could result in withdrawal of the employment offer and/or termination of employment. I further agree that I will be subjected to this compliance verification at hire and monthly thereafter and that inclusion on these lists at any time throughout my employment could result in termination.
I agree that I must undergo a post-offer medical examination, and annually thereafter, conducted by a Health Agency selected by Laboratory Alliance, as a condition of initial hire and continued employment.
I hereby authorize the educational institutions listed in this application or any current/former employer to release to Laboratory Alliance of Central New York, LLC any transcripts, placement folders, evaluations and/or references concerning my prior education/employment.
I release the above stated institution or any current/former employer and Laboratory Alliance of Central New York, LLC from any and all liabilities resulting from the release of such information.
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