Qualia Clinical Services | Research With Results

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Contact Us Toll Free
Global	1 866 629 7100
Local	402 697 6500
E-mail	General Inquires

We Are An Equal Opportunity Employer
We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

Position Applied For

Date of Application

Date Available For Work

Desired Salary Range

How Did You Learn About Us?

Careerlink.com

Employee Referral (Employee's Name)

Employment Agency

Friend

Inquiry

Relative

Other

Last Name

First Name

Middle Name

Address 1

Address 2

City

State

Zip

How Long?

Phone

E-mail Address

Social Security Number

Have you ever filed an application with us before?

Yes No

If Yes, give date and location

Have you ever been employed with us before?

Yes No

If Yes, give date and location

Do any of your friends or relatives work for us?

Yes No

If Yes, give name and location

Are you over the age of 18?

Yes No

(you may be required to provide work authorization)

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes No

Proof of citizenship or immigration status will be required upon employment

Have you ever been discharged from any employment or asked to resign?

Yes No

If Yes, give date and reason

Have you ever been convicted of a crime or violation other than a minor traffic infraction?

Yes No

If Yes, give date and reason

A conviction will not necessarily automatically disqualify you for employment. Factors such as job relations, age and time of offense, seriousness and nature of the violation, and rehabilitation will be considered.

Do you have a valid driver’s license?

yes No

If Yes, give state and number

Are you currently employed?

Yes No

If yes, may we contact your present employer?

Yes No

What is your availability?

Full Time Part Time PRN

If part time, please check days available

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

If part time, please check shifts available

Mornings
Afternoons
Evenings

Can you travel if a job requires it?

Yes No

EDUCATION

Level	School and Address	Course of Study	Years Completed	Diploma / Degree
High School
Undergraduate College
Graduate / Professional
Other (Specify)

CERTIFICATION: State any skills, specialized training, and qualifications acquired from employment or other experience.

1.		5.
2.		6.
3.		7.
4.		8.

JOB-RELATED MILITARY TRAINING: Describe any job-related training received in the United States military.

1.		5.
2.		6.
3.		7.
4.		8.

SPECIALIZED SKILLS:

Skills		Computer Programs	Other Software	Programming Languages
Type	WPM	Lotus 123 WordPerfect Access
Shorthand	WPM	Excel Word Monarch
10-Key	KPH	Lotus Notes Power Point Outlook

Do you object to working on weekends?

Yes No

NOTE: Due to fluctuations in demands or business necessity, you may be required to work overtime, including mandatory attendance for annual inventory.

Consistent attendance and punctuality are essential requirements of every job with this company. Is there anything that would interfere with your regular attendance and punctuality, if you are offered a job with the company?

Yes No

If Yes, please explain

This section must be completed in full. • A resume may not be submitted as a substitute.

WORK EXPERIENCE: Beginning with your present or last job, provide at least 7 years employment history. Attach extra pages as needed. Please list the complete mailing address, street number, city, state and zip code.

Employer	Dates Employed		Work Performed
Address	From	To
Telephone Number
Starting/Present Job Title	Hourly Rate / Salary
Supervisor	$ Starting	$ Final
Reason for Leaving			May We Contact Yes No
Employer	Dates Employed		Work Performed
Address	From	To
Telephone Number
Starting/Present Job Title	Hourly Rate / Salary
Supervisor	$ Starting	$ Final
Reason for Leaving			May We Contact Yes No
Employer	Dates Employed		Work Performed
Address	From	To
Telephone Number
Starting/Present Job Title	Hourly Rate / Salary
Supervisor	$ Starting	$ Final
Reason for Leaving			May We Contact Yes No
Employer	Dates Employed		Work Performed
Address	From	To
Telephone Number
Starting/Present Job Title	Hourly Rate / Salary
Supervisor	$ Starting	$ Final
Reason for Leaving			May We Contact Yes No
Employer	Dates Employed		Work Performed
Address	From	To
Telephone Number
Starting/Present Job Title	Hourly Rate / Salary
Supervisor	$ Starting	$ Final
Reason for Leaving			May We Contact Yes No

COMMENTS: Include explanation of any gaps in employment.

PERSONAL/PROFESSIONAL REFERENCES: Do not include family members.

Name	Phone Number	How Long Known	Best Time to Call	Occupation
1.
2.
3.

CERTIFICATION / APPLICANT’S STATEMENT:

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I authorize you to communicate with persons listed as references, former employers, and any others with whom you desire to check. I agree to hold such persons harmless with respect to any information they may give about me.

This application for employment shall be considered active for a period of time not to exceed 60 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Qualia Clinical Services is of an At Will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this Act Will employment relationship may not be changed by any written document or by conduct unless an authorized executive of Qualia Clinical Services specifically acknowledges such change in writing. I also understand that I must give two weeks prior notice of my intent to leave in order to be considered resigned in good standing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Depending upon the position, the following may be conducted prior to employment: pre-employment drug test, criminal background check, applicant testing, license and educational verification.

If employed, I agree to engage in no outside activity which would involve a conflict of interest with, or which could reflect adversely on the Company. I understand this decision is to rest with the Company. If employed, I agree to hold in strictest confidence any information concerning the Company, its Participates and its Clients, which may come to my knowledge.