Lillestol Research LLC - Clinical Trials and Research

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Personal Information

1. Date 2/7/2012
2. First Name *
3. Middle Initial *
4. Last Name *
5. Position for which you are applying
6. Address *
7. City *
8. State * Please select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington DC Washington State West Virginia Wisconsin Wyoming
9. ZIP Code *
10. E-mail *
11. Primary Phone (with area code) *
12. Other Phone (with area code)
13. Are you currently employed? *

    Yes No
14. May we contact your employer? *

    Yes No N/A
15. Seeking *

    Full-time Part-time
16. When are you available to start?
17. Earnings Expected
18. This position requires that you are at least 18 years old. Can you meet that requirement? *

    Yes No
19. If hired, can you furnish proof that you are eligible to work in the U.S.? *

    Yes No
    If no, please explain
20. Have you applied at, or worked for Lillestol Research before? *

    Yes No
    If yes, when? (month/year) If yes, what was your position?
21. Have you ever been convicted of abuse? *

    Yes No
    If yes, please explain (include date)
22. Have you been convicted of a felony in the last seven years? *

    Yes No
    If yes, please explain (include date)
23. Have you ever been disciplined or discharged by an employer? *

    Yes No
    If yes, please explain (include date)
24. Referral Source (check all that apply) *

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    Please identify
    Employee
    Please identify
    Other
    Please identify
25. Do you have any friends, relatives, or acquaintances working for Lillestol Research?

    Yes No
    If yes, please state name(s) and relationship(s)
26. Do you have a medical background, education, or training?

    Yes No
    If yes, please describe, specifying in what areas of medicine
27. Do you have clinical research experience?

    Yes No
    If yes, please describe
28. Do you have any certificates, honors, or awards that may be applicable to this position?

    Yes No
    If yes, please describe
29. Do you have any other experience, training, qualifications, or skills which may apply?

    Yes No
    If yes, please explain

Education

1. High School * Location (city, state) *
   Did you graduate? *

   Yes No
2. College Location (city, state)
   Did you graduate?

   Yes No Current Student
   Degree and Area of Study Number of Years Attended
3. Other (school name) Location (city, state)
   Did you graduate?

   Yes No Current Student
   Degree and Area of Study Number of Years Attended

Employment Record

Start with current/most recent employment and work backward. Include military experience.

Employer 01

1. Employer *
2. Location (city, state) *
3. Phone Number (include area code) *
4. Dates Employed *
5. Position Held *
6. Duties Performed *
7. Supervisor *
8. Ending Pay *
9. Reason for Leaving *

Employer 02

1. Previous Employer
2. Location (city, state)
3. Phone Number (include area code)
4. Dates Employed
5. Position Held
6. Duties Performed
7. Supervisor
8. Ending Pay
9. Reason for Leaving

Employer 03

1. Previous Employer
2. Location (city, state)
3. Phone Number (include area code)
4. Dates Employed
5. Position Held
6. Duties Performed
7. Supervisor
8. Ending Pay
9. Reason for Leaving
10. May we contact your previous employers? *

    Yes No
    If no, please explain

References

Please do not include family members; employment references preferred.

Reference 01

1. Name *
2. Phone Number (include area code) *
3. City, State *
4. Relationship *
5. Number of Years Known *

Reference 02

1. Name *
2. Phone Number (include area code) *
3. City, State *
4. Relationship *
5. Number of Years Known *

Reference 03

1. Name *
2. Phone Number (include area code) *
3. City, State *
4. Relationship *
5. Number of Years Known *

Availability

Number of Hours Seeking Per Week

1. Minimum *
2. Maximum *

Hours Available (indicate AM and PM)

1. Monday

   Earliest Latest
2. Tuesday

   Earliest Latest
3. Wednesday

   Earliest Latest
4. Thursday

   Earliest Latest
5. Friday

   Earliest Latest
6. Please provide any other relevant qualifications to the position for which you are applying.

Pre-Employment Statement

1. Any offer of employment I may receive from Lillestol Research is contingent upon my successful completion of the agency′s pre-employment review process including the agency′s receiving references that it considers satisfactory.
2. I understand that as a condition of employment at Lillestol Research, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of Lillestol Research. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to Lillestol Research.
3. In processing my application for employment, the agency may verify all information provided by me including, but not limited to, my prior employment, military record, education, character, general reputation, personal characteristics, and criminal record.
4. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the company, and I understand that my compensation and conditions of employment can be changed by the company at any time. I understand that any employment relationship with Lillestol Research is of an "at-will" nature, which means that the employee may resign at any time, and the employer may discharge at any time without cause.
5. By my signature, I promise that information provided in this employee application (and in any related documentation) is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from consideration for employment, and may lead to my dismissal from employment, if discovered at a later day.
6. I authorize any person, school, current or prior employer named in this form (or related documentation or interview) to provide Lillestol Research with any information and opinion requested by Lillestol Research in connection with my application, and I release such persons, employers, and schools from any liability in making such statements.
7. I understand that this application does not create a contract of employment. I understand that, if hired, I am obliged to comply with any and all current and subsequently adopted Lillestol Research policies, and that Lillestol Research does not offer contracts, promises, or representations related to employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of wages or salary, be terminated at any time and for any reason.

By entering my name in the box below, I understand that I will submit an electronic signature, stating that I have read the above "Pre-Employment Statement", I understand it fully, and I will adhere to it.

1. Please enter your full name *
2. Please upload your resume *