Application For
Employment
ABC Research Corporation
3437 S.W. 24th Ave.
Gainesvile, FL 32607
Phone:352-372-0436
Fax:352-378-6483

Personal Information
Name:
Date:
Social Security Number:
Home Address:
City, State, Zip:
Home Phone:
Business Phone:
US Citizen:
If Not Give Visa No. & Expiration:

Position Applying For
Title:
Salary Desired:
Referred By:
Date Available:

Full Time
Part Time
 
Temporary

Education
High School(Name, City, State):
Graduation Date:
Business or Technical School:
Dates Attended:
Degree, Major:
Undergraduate College:
Dates Attended:
Degree, Major:
Graduate College:
Dates Attended:
Degree, Major:

References
Name:
Address:
Phone:
Name:
Address:
Phone:
Name:
Address:
Phone:

FORMER EMPLOYERS (List Below Last Three Employers, Starting With Most Recent One First)

Employer
 
Street
Address
 
City
 
State
 
Zip
 

Supervisor's Name
 
Phone
 

Employed
From
 
To
 


Salary
Beginning
 
Ending
 
Describe Work Done
 
 
 
 
Reason For Leaving
 
 
 
 


Employer
 
Street
Address
 
City
 
State
 
Zip
 

Supervisor's Name
 
Phone
 

Employed
From
 
To
 


Salary
Beginning
 
Ending
 
Describe Work Done
 
 
 
 
Reason For Leaving
 
 
 
 


Employer
 
Street
Address
 
City
 
State
 
Zip
 

Supervisor's Name
 
Phone
 

Employed
From
 
To
 


Salary
Beginning
 
Ending
 
Describe Work Done
 
 
 
 
Reason For Leaving
 
 
 
 


In Case of Emergency, Notify:
 
 
(Name)
(Phone)

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED IN THIS APPLICATION. I UNDERSTAND THAT MISREPRESENTATION OR OMISSION OF FACTS CALLED FOR IS CAUSE FOR DISMISSAL. FURTHER, I UNDERSTAND AND AGREE THAT MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT ANY PREVIOUS NOTICE.

DATE
 
SIGNATURE
 



PRE-EMPLOYMENT DRUG TESTING
CONSENT AND RELEASE FORM


I hereby consent to submit to urinalysis and/or other tests as shall be determined by ABC Research Corporation in the selection process of applicants for employment, for the purpose of determining the drug content thereof.

I agree that a designated laboratory may collect these specimens for these tests and may test them or forward them to a testing laboratory designated by the company for analysis.

I further agree to and hereby authorize the release of the results of said test to the company.

I further agree to hold harmless the company and its agents (including the above named physician or clinic) from any liability arising in whole or in part, out of the collection of specimens, testing, and use of the information from said testings in connection with the company's consideration of my application of employment.

I further agree that a reproduced copy of this pre-employment consent and release form shall have the same force and effect as the original.

I have carefully read the foregoing and fully understand its contents. I acknowledge that my signing of this consent and release form is a voluntary act on my part and that I have not been coerced into signing this document by anyone.


Applicant
Print Name:
 
S.S.#:
 
 
Applicant
Signature:
 
Date:
 



Witness Printed Name:
 
 
 
Witness Signature:
 





OVER-THE-COUNTER AND PRESCRIPTION DRUGS WHICH COULD
ALTER OR AFFECT THE OUTCOME OF A DRUG TEST

ALCOHOL
All liquid medications containing ethyl alcohol (ethanol). Please read the label for alcohol content. As an example, Vick's Nyquil is 25% (50 proof) ethyl alcohol, Comtrex is 20% (40 proof), Contac Severe Cold Formula Night Strength is 25% (50 proof) and Listerine is 26.9% (54 proof).

AMPHETAMINES
Obetrol, Biphetamine, Desoxyn, Dexedrine, Didrex

CANNABINOIDS
Marinol (Dronabinol, THC)

COCAINE
Cocaine HCI topical solution (Roxanne)

PHENCYCLIDINE
Not legal by prescription.

METHAQUALONE
Not legal by prescription.

OPIATES
Paregoric, Parepectolin, Donnagel PG, Morphine, Tylenol with Codeine, Empirin with Codeine, APAP with Codeine, Aspirin with Codeine, Robitussin AC, Guiatuss AC, Novahistine DH, Novahistine Expectorant, Dilaudid (Hydromorphone), M-S Contin and Roxanol (morphine sulfate), Percodan, Vicodin, etc.

BARBITURATES
Phenobarbital, Tuinal, Amytal, Nembutal, Seconal, Lotusate, Fiorinal, Fioricet, Esgic, Butisol, Mebaral, Butabarbital, Phrenilin, Triad, etc.

BENZODIAZEPINES
Ativan, Azene, Clonopin, Dalmanc, Diazepam, Librium, Xanax, Serax, Tranxene, Valium, Verstran, Halcion, Paxipam, Restoril, Centrax.

METHADONE
Dolohine, Methadose

PROPOXYPHENE
Darvocet, Darvon N, Dolene, etc.

LIST PRESCRIPTION DRUGS TAKEN WITHIN THE PAST 30 DAYS. THIS IS FOR YOUR USE ONLY AT THIS TIME.
 
 








Disclosure and Release of Information Authorization Consumer Report/Investigative Consumer Report Important: Please read carefully

As an applicant for employment or an employee, you are a consumer with rights under the Fair Credit Reporting Act. When evaluating you for employment, promotion, reassignment, or retention as an employee, a consumer report or an investigative consumer report may be obtained from a consumer-reporting agency and may be obtained any time during the application process or during your employment.

I authorize ABC Research Corporation and Edge Information Management, Inc., a consumer reporting agency, to obtain information from all personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement agencies at the federal, state or county level, relating to my past activities, to supply any and all information concerning my background. The information obtained may include, but is not limited to, academic, residential, achievement, previous employment, verification and/or job performance, worker’s compensation, professional licenses, credit report, driving history, and criminal history records.

I understand that a Consumer Report or Investigative Consumer Report may be prepared summarizing this information. The report may include information obtained through personal interviews regarding my character, general reputation, personal characteristics as well as a written summary of my rights under the Fair Credit Reporting Act. If requested, the consumer-reporting agency will explain the contents of my file. I understand that proper identification will be required and that I should direct my request to: [Edge Information Management, Inc., 100 Rialto Place, Suite 800, Melbourne, Florida 32901-3004 Phone number 1-800-725-3343]. I also understand that if my driving record abstract is obtained from Louisiana that this record will be obtained through American Driving Records.

I understand that by requesting this information, no promise of employment is being made. I also understand that a photocopy of this authorization be accepted with the same authority of as the original; and that if employed by ABC Research Corporation this authorization will remain in effect throughout such employment. I understand that the information requested below regarding date of birth, race and sex is for the sole purpose of gathering the above information accurately, and will not be used to discriminate against me in violation of any law.

READ, ACKNOWLEDGED AND AUTHORIZED

 
 
 
Signature
 
Date
 
 
Name:  First                       Middle
Last
Maiden



NOTE: I am providing the following voluntarily.
PLEASE PRINT CLEARLY

Social Security #
 
Date of birth(for ID purposes):
 

Sex:
 
Race:
 
Driver’s License #
 
State:
 



Current Address:
 
 
Previous Address: