Midland Health · Tester Application

Fill out the following form as complete as possible and a representative from our office will contact you.

 Contact Information 
First name:
Last name:
Company:
Street:
City:
State:
Zip:
Phone:
Email:
 Availability/Misc. Experience 
How far are you willing to travel?
What days are you available to work?
Do you have a felony conviction? Explain:

Years Drawing Blood: Years
Last Blood Draw:
Do you know OSHA standards?
Spoken Language(s):
Most Recent Pay Rate:
 Work History (Most recent first) 
Company Name:
Phone:
Your Title:
Supervisor:
Rate Of Pay:
Start Date:
End Date:
Reason For Leaving:
 Work History (cont.) 
Company Name:
Phone:
Your Title:
Supervisor:
Rate Of Pay:
Start Date:
End Date:
Reason For Leaving:
Education
High School:
Graduated:
College:
Graduated/Degree:
Medical Training:
Special Skills
I can...




I am...




I own...




References
Name:
Phone:
Relation:
   
Name:
Phone:
Relation:
   
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Phone:
Relation:
   
Agreement Of The Transfer Of Information
By checking the box to the left, I declare the information provided by me is true, correct and complete to the best of my knowledge. I understand that if there are any falsifications, omission of fact in connection with my application, whether on this document or not, may result in immediate termination of contractorship. I authorize you to verify any and all information provided in this application.