Office Laboratory Assistant Employment Verification Form

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OFFICE LABORATORY ASSISTANT EMPLOYMENT VERIFICATION FORM
Instructions: Print this form. Be prepared to upload the completed, signed and dated form during your
online application process. Instructions for submission will be provided during your online application
process.
Office Laboratory Assistant Applicant Name: _________________________________
Laboratory Director Name: _______________________________________________
Laboratory Name: _____________________________________________________
Laboratory License Number (currently licensed laboratory):____________________; OR
Laboratory Application Online Verification Number (laboratory has applied for a license but has not
received it yet):_________________________________________________________
I certify that the office laboratory assistant applicant named above is employed by the laboratory named
on this document.
Laboratory Director’s Signature: __________________________________________
Date: ________________________________________________________________
 This form must be signed by the laboratory director; no other signature will be accepted.

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