Medical Eye Center At-Will Employment Application

At-Will Employment Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, marital or veteran status, disability, sexual orientation or any other legally protected status recognized by local, state or federal law.
This application will remain active for 180 days.
Position Applying For *
Date *

Month Day Year
Date of application
How did you learn about us? *
Date available to work *

Month Day Year
Date
Choose work availability *

Full Time Part Time Shift Work Temporary
Can you travel if a job requires it? *

Yes No
Have you ever filed an application with us before? *

Yes No
If "Yes" when?
Type Date
Have you ever been employed with us before? *

Yes No
If "Yes" when?
Type Date
APPLICANT INFORMATION
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Can you provide proof of your eligibility to work in the United States? Proof of eligibility to work in the United States will be required upon employment. *

Yes No
Are you currently employed? *

Yes No
Are you currently on “layoff” status or subject to recall? *

Yes No
May we contact your current employer? *

Yes No
EDUCATION
High School
State
Course of Study
Diploma / Degree
College
State
Course of Study
Diploma / Degree
Other
State
Course of Study
Diploma / Degree
INDICATE ANY FOREIGN LANGUAGES YOU SPEAK, READ, AND / OR WRITE
Language
For the language above, please check all that apply.

Certified Translator Fluent: Speaking Fluent: Reading Fluent: Writing Good: Speaking Good: Reading Good: Writing Fair: Speaking Fair: Reading Fair: Writing
Language
For the language above, please check all that apply.

Certified Translator Fluent: Speaking Fluent: Reading Fluent: Writing Good: Speaking Good: Reading Good: Writing Fair: Speaking Fair: Reading Fair: Writing
PROGRAMS AND EQUIPMENT USED
Please check all that apply

PC Fax Machine Credit Card Machine MS Word MS Excel Nextech Centricity Epic Refracting System OPTOS OCT Phoropter Tono Pen Slit Lamp Fundus Photography
OTHER JOB RELATED TRAINING, APPRENTICESHIP OR SKILLS ACQUIRED FROM EMPLOYMENT OR OTHER
STATE ANY ADDITIONAL INFORMATION YOU FEEL MAY BE HELPFUL TO US IN CONSIDERING YOUR APPLICATION
EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude information or organizations that indicate race, color, religion, gender, national origin, age, ancestry, disabilities, sexual orientation or other protected status.
Employer
Phone Number

Area Code Phone Number
Supervisor
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Duties
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason for Leaving

Additional Employer
Employer
Phone Number

Area Code Phone Number
Supervisor
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Duties
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason for Leaving

Additional Employer
Employer
Phone Number

Area Code Phone Number
Supervisor
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Duties
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason for Leaving

Additional Employer
Employer
Phone Number

Area Code Phone Number
Supervisor
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Duties
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason for Leaving

Additional Employer (Click here to continue the application)
Employer
Phone Number

Area Code Phone Number
Supervisor
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Duties
Start Date

Month Day Year
Date
End Date

Month Day Year
Date
Reason for Leaving
ADDITIONAL EXPERIENCE
List professional, trade, business, or civic activities and offices held. You may exclude information or memberships that would reveal gender, race, color, religion, national origin, age, ancestry, disability, sexual orientation or other protected status.
PROFESSIONAL REFERENCES

Please list three professional references.
Reference 1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reference 2 *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reference 3 *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
APPLICANT’S STATEMENT

I certify that answers given herein are true and complete to the best of my knowledge.I authorize investigation of all statements contained in this application for employment as may be necessary and allowed by law in arriving at an employment decision.I understand that all prospective employees must submit to a controlled substance test upon a conditional offer of employment. I understand that if I decline to consent and therefore decline to take the controlled substance test, the conditional offer of employment will be withdrawn.I understand and acknowledge that, if hired, my employment relationship with this organization would be of an “AT WILL” nature, which means that I may resign at any time and the Employer may discharge me at any time and for any or no reason. It is further understood that this “AT WILL” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.I understand that false or misleading information given in my application or interview(s) may result in disqualification from consideration of future employment and discharge (if I am hired) I understand, also, that I am required to abide by all rules and regulations of the employer, and applicable state and federal law.
Signature *

Clear
*

Month Day Year
Date
*WE ARE AN AT-WILL, DRUG FREE, EQUAL OPPORTUNITY EMPLOYER
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