APPLICATION FOR EMPLOYMENT

Step 1 of 4

25%

Date

MM slash DD slash YYYY

Name

First Middle Last Maiden

Present address

Address

Number Street Address City State / Province / Region ZIP / Postal Code

E-mail address

Home Telephone

Cell phone

If under 18, please list age

Position applied for (1)

and salary desired (2)

Days/hours available to work

No Pref

Mon

Tue

Wed

Thur

Fri

Sat

Sun

How many hours can you work weekly?

Can you work nights?

Yes

Employment desired

FULL-TIME ONLY

PART-TIME ONLY

FULL- OR PART-TIME

When are you available for work?

High School:

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

College:

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

Bus. or Trade School:

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

Professional School:

NAME OF SCHOOL

LOCATION (Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

Describe what best qualifies you for the position.

Give an example of great patient care.

Describe the perfect medical office to work for

Which of these is the most important core value?

Integrity

Excellence

Quality Care

Why did you answer as you did to the core value question?

Computer Skills

Check off those computer skills with which you are proficient (any version).

PC User

Windows

OfficeMate

Exam Writer

Microsoft Word

Microsoft Excel

Internet

Web design

Other

Skills

Please list two references other than relatives or previous employers that we may contact:

Name

Position

Address

Telephone

Please list any other special skills you may have, e.g., fluency in other languages, licenses, special training required for the position for which you are applying for, etc.

DO YOU HAVE ANY SPECIAL CERTIFICATIONS?

Yes

Specialty

Date(s)

Work Experience

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer

First Last

Address

City State / Province / Region ZIP / Postal Code

Phone number

Name of last supervisor

First Last

Employment dates

From

MM slash DD slash YYYY

Pay or salary

Start

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer

First Last

Address

City State / Province / Region ZIP / Postal Code

Phone number

Name of last supervisor

First Last

Employment dates

From

MM slash DD slash YYYY

Pay or salary

Start

Final

Your Last Job Title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer

First Last

Address

City State / Province / Region ZIP / Postal Code

Phone number

Name of last supervisor

First Last

Employment dates:

From To

MM slash DD slash YYYY

Pay or salary

Start

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer

First Last

Address

City State / Province / Region ZIP / Postal Code

Name of last supervisor

First Last

Employment dates

From

MM slash DD slash YYYY

Pay or salary

Start

Final

Your last job title

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

May we contact your present employer?

Yes

Did you complete this application yourself

Yes

who did?

AGREEMENT (PLEASE READ CAREFULLY BEFORE SIGNING)

I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that misleading or false statements will constitute sufficient cause for refusal of hire or termination of my employment.

I understand that neither the acceptance of this application nor the subsequent entry into any type of employment relationship with PREMIER VISION creates an actual or implied contract of employment. I understand that, if I accept employment with PREMIER VISION, it will be on an at-will basis. This means that either PREMIER VISION or I have the right to terminate the employment relationship at any time, for any reason, with or without cause.

I agree to submit to drug and alcohol testing, if requested by PREMIER VISION. I release PREMIER VISION, and its employees, plus other persons or companies, from any and all liability arising out of or related in any way to such testing.

I authorize PREMIER VISION to investigate information concerning my education, employment experiences and all other aspects of my background relevant to my proposed employment. I release PREMIER VISION and its employees from all liability arising from such investigation.

Signature of applicant

Date

MM slash DD slash YYYY

PREMIER VISION is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with PREMIER VISION depends solely on your qualifications.