Thank you for your interest in Vision Care Associates!

It is the policy of Vision Care Associates to provide equal employment opportunities to all qualified persons without regard to race, creed, color, religious belief, sex, age, national origin, physical or mental handicap or veteran status.

* Indicates Response Required

PERSONAL INFORMATION

First Name *

M.I.

Last Name *

Current Address

Street and Apt. # *

City *

State *

Zip Code *

Permanent Address (if different from above)

Street and Apt. #

City

State

Zip Code

Telephone *

E-mail *

Soc Sec # *

Driver's License # *

State Issued *

I am a U.S. Citizen or otherwise authorized to work
in the United States on an unrestricted basis. *

Yes

No

If applicable, please list your visa type, visa #, and expiration date.

Have you ever been convicted of a felony? *

Yes

No

If you answered yes, please explain.

Have you ever served in the U.S. Military? *

Yes

No

If yes, please provide your branch of service, rank at time of separation, service dates, and any special honors.

EMPLOYMENT HISTORY

Present or Most Recent Employer

Employer *

Address *

Your Position *

Salary *

Dates of Employment *

Duties *

Supervisor Name *

Supervisior Title *

May we contact? *

Reasons for Leaving *

Prior Employer

Employer

Address

Your Position

Salary

Dates of Employment

Duties

Supervisor Name

Supervisior Title

May we contact?

Reasons for Leaving

Prior Employer

Employer

Address

Your Position

Salary

Dates of Employment

Duties

Supervisor Name

Supervisior Title

May we contact?

Reasons for Leaving

EDUCATION

High School

School Name and Address *

Did you graduate? *

Yes

No

If you did not graduate, did you receive your GED?

Yes

No

Special Honors/Awards

Technical or Vocational School

School Name and Address

Did you graduate?

Yes

No

Degree or Certification

Specialty

Special Honors/Awards

College or University

School Name and Address

Did you graduate?

Yes

No

Degree

Major

Special Honors/Awards

College or University

School Name and Address

Did you graduate?

Yes

No

Degree

Major

Special Honors/Awards

POSITION INFORMATION

Position Applying For *

How did you hear about this job? *

What hours are you willing to work? *

Would you be able to work weekends? *

Yes

No

When would you be able to start? *

Desired Salary *

Per *

SKILLS

Computer Skills

Languages Spoken (other than English)

Other Skills

I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history.

Furthermore, I understand that if I am hired, employment with Springfield Vision Care Associates is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.

Signature: *

Date *

© Vision Care Associates

1-800-272-7393