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ONELIFE EXAM
APPLICATION FOR EMPLOYMENT
This section must be completed ( *Indicates a required field ).
*
*
Last Name
 *
 Middle Name
First Name
*
 *
 *
Birth Date
Social Security
 Driver's License
*
*
 State Issued
Address 2
Address 1
*
*
 State
 Zip Code
*
Apt / Ste / PO Box
 City
*
 *
*
 *
 Are you legal to work in the U.S.?
Age
Nationality
 Gender
*
 Language Spoken
Home Phone
 Cell Phone
*
 School Attended
Degree / Diploma
*
 Date Completed
*
School Attended
*
 Certificate / Training
Date Attended
*
*
*
Expiration Date
State Med License
 State Issued
Availability
Position Desired
Salary Desired
Full Time
 Email Address
Part-Time
 Part Time On-Call
Employment History
Please tell us about your employment history in the past 5 years.  You MUST fill out at least more than one
employment record  if,  applicable.  Please start with your recent employer.  Please answer all questions carefully and
completely. Any false or misleading information may be grounds for immediate discharge or denial of offer for an
employment. Asterisk (*) is a required field.
Most Recent Employer
*
*
 Employer
Address
*
*
Job Title
Dates Employed
Salary
*
Work Phone
 Ext
Dept
Supervisor
Employment Status:
Reason for leaving
Employed
 Not Employed
*
May we contact your employer ?
No
Yes
 No
 Yes
May we conduct background check?
*
Duties
Previous Employer
*
Employer
 Address
*
*
Salary
*
 Dates Employed
Job Title
*
Dept
Ext
Supervisor
Work Phone
Employment Status:
Employed
Not Employed
Reason for leaving
*
May we contact your employer ?
Yes
 No
 May we conduct background check?
 Yes
No
*
Duties
Previous Employer
*
*
Address
Employer
*
*
 Salary
Dates Employed
Job Title
*
Supervisor
Ext
Dept
Work Phone
Reason For Leaving
*
May we contact your employer ?
No
No
 Yes
Yes
 May we conduct background check?
*
Duties
Education And Training
*
 Address
School Name
Type of school
Dates Attended
 No
Graduate?
 Yes
Degree
 Special Training
*
School Name
 Address
Yes
Type of school
Graduate?
 No
Dates Attended
Degree
Special Training
Professional References
*
Please list 2 people with whom you have a professional relationship.
Name
 Position
 Company
 Phone
 Ext
 Yrs Known
Company
Name
 Position
 Phone
 Ext
 Yrs Known
Personal References
*
Please list 3 people whom you know , not living with you.
Name
Address
Phone
 Relationship
Name
 Address
 Phone
 Relationship
Name
 Address
 Phone
 Relationship
Qualifying Questions
Any misleading or inaccurate information will be  ground for dishonesty or breach of trust, which, may affect your
application to get a job. Please answer the following questions ( * Required ).
Have you ever been an agent for life insurance? *        
Does anyone in your  family work for an insurance company? *        
Have you ever been employed in a paramedical exam company? *
If yes, when?
Where?
Have you ever been employed in a medical / dental billing company?
If yes, when?
 Where?
Are you currently working in a paramed / medical / dental company? *
Are you eligible for employment in the U.S.? *        
Do you have legal papers,  to show your eligibility to work in the U.S.? *
Can you produce documentation which can establish your identity? *        
Are you at least 18 years of age? *
If you are under 18, and it is required by your state, do you have a work permit? *        
Can you perform blood draw ? *        
Are you certified and license to perform venipunctures and blood draw?*        
Do you know how to perform or have been trained to do paramed exams? *        
If yes, where?
When?
Can you perform EKG/ECG test? *        
Do you know how to use and operate EKG/ECG machine? *
Do you have a valid drivers license to operate a vehicle  for transportation? *
Do you have a valid auto  insurance? *        
Are you willing to be assigned in the field to perform mobile exam? *
Have you ever been convicted of a felony or misdemeanor (s)? *        
If yes, what offense, please explain: *
Do you speak and write any languages other than English? *
What language you can speak and write, please explain: *
Onelife Exam is in compliance with the Violent Crime Control and Law Act of 1994, we does not authorized
the performance of services by any individual who has been convicted of a felony involving dishonesty or
a breach of trust that may have  a bearing on job performance.
How did you learn about us?
Web site        
Friend        
 Email
Employee Referral
School
Ads / Newspaper etc. ( Be specific )
Do you want to become an independent contractor in the future?
Do you have a direct contact to life insurance agent?
Name of contact person:
 Contact Info:
Name of person to notify in case of emergency:
Relationship
Notice to Applicant

Onelife Exam is an equal opportunity employer, we do  not discriminate on the basis of sex, race, color, creed,
religion, national origin, age, disability or any other characteristic protected by Federal, State or Local Laws. Onelife
Exam will make a reasonable accommodation to known physical or mental limitations of a qualified applicant with
disability unless the accommodation would impose an undue hardship on the operation of our business  and safety of
the applicant.

We may imposed or required applicants to take and pass a post-offer drug test and background check,  if,
may be deemed necessary , and the examination will be at company expense.  We may also require a post-offer
examination test,  to ensure eligibility  for the position being applied for. Failure to pass any of the above will result in
the immediate withdrawal of the offer of  employment.

Completion of this application does not assure an interview or employment with Onelife Exam. We reserved the right to
investigate and verify the information, records, and documents  submitted to us. We
also, reserved the right to accept or withdraw the offer of employment  if, we may find any unsatisfactory
results or findings on your application.

Your application will remain current and active for 60 days from the date of application. If you wish to renew your
application for employment after 60 days, you must fill out another application.

In order to complete the application for employment, please  submit the following documents either by Fax or Mail:

1. A Photo  copy  of  your  recent driver's license.  We must be able to see your face clearly.
2. A copy  of  your social security  number.
3. A copy of  your  certification for Phlebotomy / laboratory assistant / Paramedic or any professional license
necessary  to perform venipuncture or blood draw.
4. A proof of  valid car or auto  insurance coverage.
5. If you refused and requested  not  to contact  your employer  for whatever reason you may  have. You  may  need to
provide us a copy of your 1099, pay stub, or another document to provide evidence that you actually perform paramed
exams.  ( Applicable to Phlebotomist and Examiner applicant only ).
6. A proof  of employment or certification from your previous employer.

** We may not require you to submit the requirements mention from number 3, 5 and 6, if,  you are a fresh graduate or
has no previous experience or it does not apply  to the position you are applying for.  

I understand that, if offered employment,  my employment  may be terminated, at any time, and for any reason at the
option of  either the company or myself.  I understand that no company or management representative  has any
authority to enter into any agreement contrary to the foregoing.

I hereby authorized to investigate my record with my former employers  and references, and release Onelife Exam and
informants from all liability whatsoever resulting from such an investigation.

The above  information is complete and true to the best of my knowledge. I understand, that if hired, subsequent
discovery  of  any misrepresentation herein or omission of facts herein, will be cause for immediate dismissal.

I understand, that, I must send in all required documentations  before I can work with Onelife Exam.  By hitting submit, I
am accepting all the conditions stated on the “ NOTICE TO APPLICANT”.

I also understand that upon typing my name on the space provided for my electronic  signature, this will serve  as the
equivalent of my legal signature.
Applicants Electronic Signature
 Date Signed
Copyrighted @ 2006-2010 Onelife Exam. All rights reserved.