Application for Employment
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Email *
Name (First, Middle, Last) *
Full Address *
Telephone Number *
Email Address *
How did you hear we are hiring? *
Position you're applying for -  *
What is your main reason for wanting to work at an optometric office? *
Are you currently employed? *
May we contact your present employer? *
Have you ever been employed by Midwest Eye Associates in the past? *
Are you legally eligible to work in the United States? *
Are you available to work evenings and Saturdays? *
Date you are available to begin work? *
Wage requested per hour *
Do you speak any languages other than English (list – voluntary answer)
Describe any specialized training that you feel might better qualify you for this position.
RECORD OF EMPLOYMENT: Please list previous employers starting with the most recent. Please give the following information for your last three employers. (Company, City/State, Supervisor, Dates of Employment, Ending Salary, Job Duties, and Reason for Leaving) *
High School Diploma (If yes, year of graduation) *
Please list any colleges attended and degrees obtained.
PERSONAL/PROFESSIONAL REFERENCES  (Do not include family members or past supervisors) - Need three references. Please included their name, phone number, and occupation. *
May we contact all personal/professional references you've listed above?  *
PLEASE READ CAREFULLY BEFORE DIGITALLY SIGNING THIS APPLICATION - 
It is the policy of Midwest Eye Associates to ensure equal employment opportunity without discrimination or harassment on the basis of race, color, religion, sex, pregnancy, age, and / or disability. Midwest Eye Associates prohibits any such discrimination or harassment.      

I understand that consideration of this application in no way implies a contract of employment.  I understand that if an employment relationship is established, I have the right to terminate my employment at any time for any reason.  At any time during the first ninety (90) days of my employment, my position may be terminated with compensation paid through the last day worked. I understand that Midwest Eye Associates promotes a drug/alcohol free workplace and agree to abide by the guidelines established in the Policy and Procedure Manual. I understand that as a condition of my employment, I may be required to undergo screening for illegal drugs and hereby give my consent for that testing.  My refusal to submit to testing will result in my application being rejected or my employment being terminated. I certify that the answers given in this application are true and accurate to the best of my knowledge. I understand that any false information, misleading statements, or omission of facts is sufficient cause for rejection of my application if Midwest Eye Associates has not employed me and immediate termination if Midwest Eye Associates has employed me.  In the event of my employment with Midwest Eye Associates I will comply with all rules, regulations, and policies set forth in the Policy and Procedure Manual or other policies communicated to me. I hereby acknowledge that I have read and understand the preceding statements.   

            (FIRST / LAST NAME and Date)
*
A copy of your responses will be emailed to the address you provided.
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