Vermillion, Inc. Employment Application

PERSONAL INFORMATION

Date *

Last Name*

First Name*

Middle Name

Street Address*

City *

State *

Zip *

Daytime Phone *

Evening Phone

Email

Date Available*

Position Applied For *

Shift 1 Shift 2 Shift 3

EDUCATION/CERTIFICATION/SKILLS

Do you have a High School Diploma or GED?

Yes No

Please list any computer skills/experience

Microsoft Word

Microsoft Excel

Microsoft Outlook

SyteLine

Microsoft Access

Typing (WPM)

Please provide your typing speed in WPM.

Other

Please provide details.

Please list any University, High School or GED, College, Business, Technical, and/or Trade School education

Name of Institution *

City/State *

Major/Program *

Completed?

Yes No

Name of Institution

City/State

Major/Program

Completed?

Yes No

EMPLOYMENT HISTORY- LIST CURRENT OR MOST RECENT POSITION FIRST AND INCLUDE ANY MILITARY SERVICE

PROFESSIONAL REFERENCES

Name *

Relationship *

Email *

Phone *

Name *

Relationship *

Email *

Phone *

Name *

Relationship *

Email *

Phone *

How did you hear about Vermillion Incorporated?

Newspaper Job Posting

Current/Former Employee

Career Fair

Walk-In

Internet Job Posting

Recruiter or Employment Agency

Other

AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

Gender

Male Female

ETHINIC GROUP
Please check one of the descriptions below corresponding to the ethnic group with which you most identify:

White (Not Hispanic)

Native Hawaiian/Pacific Islander

American Indian/Alaskan Native

Black/African American

Hispanic/Latino

Asian

Two or More Races

VETERAN STATUS
Please check one if it describes your U.S. military, ground, naval or air service veteran status:

Not a veteran

Disabled Veteran:
A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or A person who was discharged or released from active duty because of a service connected disability.

Other Protected Veteran:
A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

Armed Forces Service Medal Veteran:
A veteran who, while serving on active duty participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Recently Separated Veteran:
A veteran who was discharged or released three or less years from this date

Covered Veteran:
A veteran as defined in the four categories above.

Applicant’s Certification and Agreement

To the best of my knowledge, all information on this application is true and correct. I authorize Vermillion, Inc. to use the information given to determine my eligibility for employment, including contacting each of my former employers listed concerning my qualifications for employment. Permission is granted to each of my former employers to give Vermillion, Inc. information regarding my work experience. I understand that fraudulent statements made in this application may be cause for disqualification for employment at or dismissal from Vermillion, Inc.

Further, I understand that any offer of employment is contingent upon satisfactory results of a drug test; therefore I agree to submit to a drug test at any time deemed appropriate by Vermillion, Inc. and as permitted by law. I understand that some positions within Vermillion, Inc. may also require satisfactory results of a medical and/or vision examination and I agree to submit to such examination at any time deemed appropriate by Vermillion, Inc. and as permitted by law. I consent to allow the test providers to disclose the results from any required drug test or medical or vision examination to Vermillion, Inc.

I hereby understand and acknowledge that all employees who do not have a written, individual employment contract with a specific, fixed term of employment approved by the President are employed for an indefinite duration “at will” by Vermillion, Inc. Absent of the aforementioned agreement and in accordance with Kansas law, I or Vermillion, Inc. may terminate my employment at any time with or without notice or cause. If I am hired, I understand that a condition of my employment will be to abide by the company’s policies, rules, and regulations.

Applicant’s Signature

Date

Date
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