* required field
Employment Application Name (last, first, mi)*
Address
Phone Number *
Check one Email address *
Are you either a U.S. citizen or an alien authorized to work in the U.S.? Are you 18 years of age or older?* Have you ever been convicted of a crime? If yes, please provide details and date
How did you hear about Midwest Eye Institute?
Have you ever applied or worked for Midwest Eye Institute before? If yes, please list dates of employment and the practice name
Reason for leaving
Position desired*
Check one How many hours a week?
Wage rate desired
Other positions for which you are qualified for
Date available to begin working
Are you currently employed?* If so, may we inquire of your present employer? Education High School
Did you graduate? College
Did you graduate? Other:
Certifications, Training, or Special Skills
Employment History Fill in the information starting with your most recent employer. Please provide at least 5 years of work history if applicable.
Employer 1
Employer phone number
Dates worked:
Position held
Supervisor name
Supervisor contact information
Starting wage
Ending wage
Bonus
Reason(s) for leaving
May we contact this employer for a reference? Employer 2
Employer phone number
Dates worked
Position held
Supervisor name
Supervisor contact information
Starting wage
Ending wage
Bonus
Reason(s) for leaving
May we contact this employer for a reference? Please list additional work history here
Skills and Other Job Related Information Please list any skills that may be related to the job for which you are applying. Do no list any organizations that would reveal race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.)
Please list any skills that may be related to the job for which you are applying. Do no list any organizations that would reveal race, color, religion, creed, national origin, ancestry, age, marital status, veteran status, non-job related disability or any other protected group status.
References Reference 1
Check one Email address
Phone number
Years known
Reference 2
Check one Email address
Phone number
Years known:
Reference 3
Check one Email address
Phone number
Years known
Other references
Authorization and Acknowledgements I affirm that the information I have provided in this application is accurate and complete. I also understand that any omission or misrepresentation of information provided may result in my rejection for, or termination from, employment.I also authorize Midwest Eye Institute to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.In the event of my employment with Midwest Eye Institute, I will comply with all of the rules and policies of the employer. I understand that if I am employed, my employment will be at-will for no set period of time, and that my employment may be terminated for any reason at any time by either me or Midwest Eye Institute.
Signature: *
Date *
