EMPLOYMENT APPLICATION

*All fields are required
Date of Application
Position Applied For:
Salary Desired
How did you hear about us?
Why do you want to work for Nationwide Vision Center?

   Personal Info
First Name
 Middle Name 
Last Name
Address (including number and street)
 City
 State
 Zip
E-Mail
Home Number
Alternate Number
If you are under 18 years of age can you
 provide proof of eligibility to work?

YES

NO

Have you ever filed an application with us before? 

YES

NO
If YES, what was the date?

Are you currently employed?

YES

NO
If so may we contact your present employer?

YES

NO

Are you legally able to work in the United States? Proof of citizenship or immigration status will be required if employed.

YES

NO
       

Are you able to work: Full-Time    Part-Time

Shift Work

 Temporary

   
         
Can you travel if a job requires it?

YES

NO

Have you been convicted of a felony within the last 7 years?

YES

NO
If yes, please explain:
(Conviction will not necessarily disqualify an applicant from employment consideration)

Did you complete high school or its equivalency?

YES

NO
If not, what level was successfully completed?

Did you complete Undergraduate/College studies?

YES

NO
If so, what was the course of study? What was your diploma/degree?

Did you complete Graduate/Professional studies?

YES

NO
If so, what was the course of study?
What was your diploma/degree?

Describe any specialized training, apprenticeships, or extra curricular activities and honors you received as well as any professional, trade or business offices held. You may exclude any memberships which would reveal sex, race, religion, national origin, age, ancestry, disability, or other protected status.

What languages can you do the following with and what level:

Speak

 Level (1=OK    5=Fluent)

   1  

   2  

    3       4    
5

Read

 Level (1=OK    5=Fluent)

   1  

   2  

    3       4    
5

Write

 Level (1=OK    5=Fluent)

   1  

   2  

    3       4    
5

Experience

List most recent employer first. Do not assume compliance by stating “see resume”. All work references will be checked so be sure you complete all information. List employment for past 10 years.
Employer
Ending Salary:
Address
Telephone Number
Dates employed from: to:
Job Title
Supervisor
Work Experience
Reason for leaving

Employer
Ending Salary:
Address
Telephone Number
Dates employed from: to:
Job Title
Supervisor
Work Experience
Reason for leaving

Employer
Ending Salary:
Address
Telephone Number
Dates employed from: to:
Job Title
Supervisor
Work Experience
Reason for leaving

Employer
Ending Salary:
Address
Telephone Number
Dates employed from: to:
Job Title
Supervisor
Work Experience
Reason for leaving

Employer
Ending Salary:
Address
Telephone Number
Dates employed from: to:
Job Title
Supervisor
Work Experience
Reason for leaving

Have you ever been dismissed from any job?

YES

NO
Which one listed?
Why?
Is there any reason why any of your past jobs would give a negative employment reference? 

YES

NO
If yes, which one and why?

   References
   Please provide first and last names, addresses, and telephone numbers of three people who are not
   related to you.

1.

 First Last Address
Phone #:

2.

 First Last Address
Phone #:

3.

 First Last Address
Phone #:
Applicant Statement
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in making an employment decision.

I understand that my possible employment at Nationwide Vision Center would be “at will”, and that Nationwide Vision Center affirms the right to terminate an employee at will, though they may not choose to exercise it.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of Nationwide Vision Center that do not violate State or Federal laws.

I further understand that Nationwide Vision Center considers applicants for all positions without regard to race, color, religion, sex, national origin, sexual orientation, age, marital or veteran status, disability, or any other legally protected status. They are an Equal Opportunity Employer.