Personal Information
Name
* Last * First * MI
Present Address


* Street * City * State * Zip
*Email
* Primary Phone No. Alternate Phone No.
Best time of day to contact you?
Do you have voicemail?
May we leave a voice message?
*Are you over the age of 18?
* Have you worked under another name?    If so, list name(s)
Other names required
* If hired, can you provide proof of your citizenship or other eligibility to be employed in the United States?
* Have you ever applied to, or worked for Eye Surgical Associates before?
If so, when?
Details required
* Do you have any relatives currently working for Eye Surgical Associates?
If yes, state name and relationship:
Details required
* Have you ever been convicted of a felony or misdemeanor?
If yes, please give details:
* Have you ever been discharged from any position?
If yes, please give details:
* Have you ever been excluded from participation in a federally funded program? (i.e. Medicare, Medicaid)
If yes, please give details:
If offered a position with our organization, are you willing to submit to a drug test?

General Information About Employment Desired
Available Positions
Salary Desired
Please check all categories you are willing to work:
If hired, date you are available to begin work:
Referral Source: (i.e. newspaper, employee, internet, etc.)
If employee referral, please list employee's name:

Professional Licenses, Registrations And/Or Certifications
Profession: State Issued: License Number:
Has your professional license (in any state) ever been on probation, suspended, revoked or limited in any way?
If so, give reason:
Certification Number Registration Number

Other Special Skills And Professional Memberships
Please list any special office or technical skills you feel are important to your possible employment with us:
Please list any professional groups in which you hold membership:

Education Background
Highest Grade Completed:
Name and Location of College or Vocational Education Major or Specialty Did you Graduate Diploma or Degree Earned (If not graduated, how many credit hours have been earned?)

References
List three work references (please do not list relatives). Include name, phone number and working relationship.
1.
2.
3.

Employment Experience

Starting with your present or last employer, please list jobs you have had. Do not omit work history because it may be unrelated to the job which you are applying. Complete all of the information requested. All fields with an asterisk (*) are required.

Do not put "see resume." An attached resume does not substitute for this information. If you have not held a previous position, please enter N/A in all fields below. Account for any time during this period that you were unemployed by stating the nature of your activities. Please indicate if you were employed under a different name.

Employer:
Supervisor:
Address & Phone Number:
Dates Employed:
Job Title:
Major Responsibilities
Ending Salary:
Reason for Leaving:
May we contact for reference?
If no, why?
Employer:
Supervisor:
Address & Phone Number:
Dates Employed:
Job Title:
Major Responsibilities
Ending Salary:
Reason for Leaving:
May we contact for reference?
If no, why?
Employer:
Supervisor:
Address & Phone Number:
Dates Employed:
Job Title:
Major Responsibilities
Ending Salary:
Reason for Leaving:
May we contact for reference?
If no, why?
Employer:
Supervisor:
Address & Phone Number:
Dates Employed:
Job Title:
Major Responsibilities
Ending Salary:
Reason for Leaving:
May we contact for reference?
If no, why?
Employer:
Supervisor:
Address & Phone Number:
Dates Employed:
Job Title:
Major Responsibilities
Ending Salary:
Reason for Leaving:
May we contact for reference?
If no, why?
Optional, Attach Resume (Please include a Cover Letter)
Resume (optional)

APPLICANT STATEMENT

I certify that all information I have provided in order to apply for and secure work with Eye Surgical Associates is true, complete and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have not knowingly withheld any information that might adversely affect my chances for employment.

I understand that any offer of employment is contingent upon successfully completing a background check which includes, but may not be limited to, verifying my eligibility to participate in federally funded programs, criminal background investigation and employment reference checking. I hereby waive any and all rights and claims I may have against Eye Surgical Associates, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains current for only six (6) months. At the conclusion of that time, if I have not heard from Eye Surgical Associates and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I agree to submit to a post offer drug test and physical examination and recognize that employment is contingent upon passing a background check and drug screen and, finally, upon successfully meeting physical requirements.

If I am hired, I understand that I am free to resign at any time, with or without cause and with or without prior notice, and Eye Surgical Associates reserves the same right to terminate my employment at any time, with or without cause and with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no employee is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by Eye Surgical Associates' president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to eliminate me from further consideration for employment or, if I have been hired, may result in my immediate discharge from Eye Surgical Associates' service, regardless of the time elapsed before discovery.

If you agree to the terms set forth above, please type "I AGREE" in the space provided:

IMPORTANT! To complete this application, you must read the paragraphs above and fill in the following blanks with your full first and last name and today's date.

You must sign and date this form
* Signature * Date