EMT

**-***** - ************/******* ******* Technician

Feb 16, 2021

Personal Information

Scroll to the bottom and click the forward arrow to continue. Please note: LabCorp refers to Laboratory Corporation of America Holdings and all of its subsidiaries. Disability Accommodation for Applicants to LabCorp LabCorp is an Equal Employment Opportunity / Affirmative Action employer and provides reasonable accommodation for qualified individuals with disabilities and disabled veterans in job application procedures. If you have any difficulty using our online system and you need an accommodation due to a disability, you may use the alternative email address below to request a reasonable accommodation: ****************@*******.*** Please be sure to provide accurate dates and information as this may be used for background and employment verification.

** = conditional fields, not required unless you complete a required field that has the ** associated with it. Personal Information

Prefix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A Legal First Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter your legal first name as it appears on your Social Security card Nicholas Do you have a legal middle name? Yes

Legal Middle Name** .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter your legal middle name as it appears on your Social Security card Matthew

Legal Last Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter your legal last name as it appears on your Social Security card Koch Suffix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preferred First Name .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nick Primary Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter numbers only (No spaces, dashes, other special characters ex. 314-***-**** and NOT 314-***-****)

845-***-****

Secondary Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter numbers only (No spaces, dashes, other special characters ex. 314-***-**** and NOT 314-***-****)

Personal Email Address .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ***********@*****.*** Current Address

When entering your address information, please use proper capitalization and punctuation, as this may be used for communications sent to you. Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346 Mount Zion Road, 0000 Apt/Unit/Suite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Marlboro Zip/Postal Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12542 Country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . United States State/Province** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York General Information

If you were referred by a current employee, please list their full name and their current email address

I am authorized to work in these countries for any employer US I am authorized to work in these countries for my present employer only US When would you be available to begin work? March 10th Will you now, or in the future require sponsorship for employment visa status? e.g. H-1B status No

Have you ever been employed by LabCorp or any of its subsidiaries, such as Covance? No

If yes, please list the name of the company **

From Date ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . To Date ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Are any of your employment and/or scholastic records under another name?

(Include maiden name)

No

If yes, please provide alternate name(s) **

Are you related to any LabCorp employees? No

If yes, please provide the names and relationships ** Years of Experience related to this job 1 - 3

Languages Fluent In .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . English Work History

** = conditional fields, not required unless you complete a required field that has the ** associated with it Employment History

Please enter all relevant employment experience for the job you are applying to with us. Please note, if you grant consent, all employment information may be verified if you are offered a position with LabCorp.

We recommend that you use your resume to fill out this section to ensure accurate completion. To add additional employers, click the "Add Employer" button below. The "Remove Last Employer" will delete all entries for the last employer that you have entered. Please enter your most recent employer first.

Employer 1

Employment Type .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Company Name** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emstar City ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poughkeepsie Zip/Postal Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Country ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . United States State ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York Start Date ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07/15/2020 End Date ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Required if Previous Employment)

Position/Title ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency medical technician Job Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Almost 2 years of 911 experience with transports May we contact for employment verification? **

(NOTE: We will only contact if/when an offer has been extended) Yes Is this employment record under another name? If so, list name here (include maiden name) **

Put n/a if not applicable

Na

If you need to add more employment history, scroll up and click on Add Employer. Professional Licenses/Certifications

** = conditional fields, not required unless you complete a required field that has the ** associated with it Professional License and Certifications

If you do not have a license or credential to enter in this section, please use the arrow below to move forward to next section. To add additional professional licenses, click the "Add License" button below. The "Remove Last License" will delete all entries for the last license that you have entered. License 1

License/Certificate Type** .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phlebotomy NCA License/Certification Number (if applicable)

Issuing Agency** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NHA Issue Date** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02/08/2021 Expiration Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02/08/2023 Country** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . United States State** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York License 2

License/Certificate Type** .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Technician NV License/Certification Number (if applicable) 462598 Issuing Agency** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NEW YORK STATE Issue Date** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12/28/2019 Expiration Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01/31/2022 Country** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . United States State** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York Electronic Signature

Laboratory Corporation of America Holdings and its affiliates (collectively "LabCorp" or the "Company") do not discriminate in hiring or employment on the basis of race, color, creed, religion, sex, sexual orientation, sexual identity, sexual expression, age, national original, disability, matriculation, marital status, political affiliation, genetic information, veteran status, citizenship status, or any other basis prohibited by law. This application for employment will be considered only for each specific position for which you apply. Future consideration will depend on reapplication. The use of this form does not obligate the Company to proceed in any way with the application process or to interview, hire or retain an individual. In the event of my employment, I will comply with all rules and regulations of the organization. I further understand that the Company may investigate my driving record and my criminal record and that a consumer credit report may be obtained. I also hereby authorize the Company to seek from all previous employers and scholastic institutions, and further authorize such entities to release to the Company, all information relating to my education and/or previous employment. I understand that my employment may be terminated in the event that the Company learns that information contained in my application or otherwise provided during the hiring process is untrue or incomplete. I understand and agree that if hired my employment will be "at-will" and for no definite period of time. Either the Company or I may terminate my employment at any time, with or without cause and with or without notice. Employment with the Company is contingent upon successful completion of LabCorp's conditions of employment, general compliance training and when applicable, special compliance training on a timely basis. I HEREBY VERIFY THAT THE INFORMATION PROVIDED ABOVE IS FULL AND COMPLETE AND TRUE AND CORRECT AND THAT PROVIDING INCOMPLETE, INCORRECT, MISLEADING OR FRAUDULENT INFORMATION MAY RESULT IN THE DISQUALIFICATION OF MY APPLICATION OR TERMINATION OF MY EMPLOYMENT WITH THE COMPANY. I further acknowledge that it is my shared responsibility to ensure that I timely satisfy all pre-employment and training requirements. Failure to satisfy any condition of employment or training requirement may result in rescission of my offer of employment, termination of employment or delay in commencement of employment. By my clicking below, I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS, THAT THE TIMELY COMPLETION OF PRE-EMPLOYMENT DRUG SCREENING TEST IS ONE OF SEVERAL CONDITIONS OF EMPLOYMENT, AND THAT THE FAILURE TO COMPLY WITH THE DRUG SCREENING REQUIREMENT OR ANY OTHER CONDITION OF EMPLOYMENT MAY RESULT IN THE REJECTION OF MY APPLICATION, THE RESCISSION OF MY EMPLOYMENT OFFER OR THE TERMINATION OF MY EMPLOYMENT. Electronic Signature

Legal First Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nicholas Legal Last Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Koch ELECTRONIC SIGNATURE: Please type your name as it is listed above: I testify that this statement is true to the best of my knowledge:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nicholas Matthew Koch Accepted

Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(will populate once you submit your information) Feb 16, 2021 05:26 pm

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