Employment

Comments
This field is for validation purposes and should be left unchanged.
Application For Employment

This practice is an Equal Opportunity Employer and will not discriminate in the hiring process based on sex, religion, race, color, age, national origin, ancestry, disability, or veteran status.

Personal Information
Date*
MM slash DD slash YYYY
Full Name*
Social Security Number*
Street Address*
City, State, ZIP*
Home Phone:*
Cell Phone:
Work Phone:
Email*

Employment History
List below last three employers, starting with most recent first. This section must be completed even if you have attached resume.
May we contact the employers listed below:*
- Yes
- No
If no, indicate which:
Employer 1
Employer Name:
Employed From:
MM slash DD slash YYYY
Employed To:
MM slash DD slash YYYY
Employer Address:
Employer Phone:
Rate of Pay:
Supervisor's Name:
State Job Title and Describe Your Work:
Reason for Leaving:

Employment History (Cont.)
Employer 2
Employer Name:
Employed From:
MM slash DD slash YYYY
Employed To:
MM slash DD slash YYYY
Employer Address:
Employer Phone:
Rate of Pay:
Supervisor's Name:
State Job Title and Describe Your Work:
Reason for Leaving:
Employer 3
Employer Name:
Employed From:
MM slash DD slash YYYY
Employed To:
MM slash DD slash YYYY
Employer Address:
Employer Phone:
Rate of Pay:
Supervisor's Name:
State Job Title and Describe Your Work:
Reason for Leaving:
Do you have any commitments to any of these employers that would limit your activities with this practice?*
- Yes
- No
If yes, please explain:

Final Acknowledgements
Explain why you feel you are a good candidate for this position:*
Resume File
Accepted file types: pdf, doc, docx, Max. file size: 50 MB.
I certify that the answers given herein are true and complete and I understand the misrepresentations, omissions of facts or incomplete information requested in this application may remove me from further consideration for employment. Additionally, if employed, any misrepresentation or omission of facts, whenever discovered, is the cause for immediate discharge without notice. I grant permission to use any information in this application to verify my statements, and I release all involved parties from any and all liability from the investigation and verification of this information.
Signature*
Date*
MM slash DD slash YYYY

Eyesight Associates