APPLICATION FOR EMPLOYMENT Step 1 of 4 25% Date MM slash DD slash YYYY Name First Middle Last Maiden Present addressAddress Number Street Address City State / Province / Region ZIP / Postal Code E-mail address Home TelephoneCell phoneIf 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 No 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 COMPLETEDMAJOR & DEGREE College:NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETEDMAJOR & DEGREE Bus. or Trade School:NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETEDMAJOR & DEGREE Professional School:NAME OF SCHOOL LOCATION (Complete mailing address) NUMBER OF YEARS COMPLETEDMAJOR & DEGREE Describe what best qualifies you for the position.Give an example of great patient care.Describe the perfect medical office to work forWhich 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 SkillsCheck off those computer skills with which you are proficient (any version). PC User Windows OfficeMate Exam Writer Microsoft Word Microsoft Excel Email Internet Web design Other Skills Please list two references other than relatives or previous employers that we may contact:Name Name Position Position Address Address TelephoneTelephonePlease 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. Add RemoveDO YOU HAVE ANY SPECIAL CERTIFICATIONS? Yes No Specialty Add RemoveDate(s) Add RemoveWork ExperiencePlease 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 numberName of last supervisor First Last Employment datesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Pay or salaryStartFinalYour 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. Add RemoveName of employer First Last Address City State / Province / Region ZIP / Postal Code Phone numberName of last supervisor First Last Employment datesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Pay or salaryStartFinalYour 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. Add RemoveName of employer First Last Address City State / Province / Region ZIP / Postal Code Phone numberName of last supervisor First Last Employment dates:From To MM slash DD slash YYYY To MM slash DD slash YYYY Pay or salaryStartFinalYour 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. Add RemoveName of employer First Last Address City State / Province / Region ZIP / Postal Code Name of last supervisor First Last Employment datesFrom MM slash DD slash YYYY To MM slash DD slash YYYY Pay or salaryStartFinalYour 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. Add RemoveMay we contact your present employer? Yes No Did you complete this application yourself Yes No 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 applicantDate 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.
