Application for Employment Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone Number(Required)Social Security Number(Required)Date of Birth(Required) MM slash DD slash YYYY Driver's License Number(Required)Email(Required) Are you currently employed?(Required) Yes No May we contact your present employer?(Required) Yes No Have you ever been employed by Midwest Eye Associates in the past?(Required) Yes No Are you legally eligible to work in the United States?(Required) Yes No Are you available to work evenings and Saturdays? Yes No Date you are available to begin work?(Required) Salary requested per hour(Required) Do you speak any languages other than English (list – voluntary answer)(Required) Add RemoveDescribe any specialized training that you feel might better qualify you for this position(Required) RECORD OF EMPLOYMENT: Please list previous employers starting with the most recent. Please give the following information for your last three employers.Nameof Company, Add RemoveCity/State Add RemoveSupervisor Add RemoveDates of Employment Add RemoveEnding Salary Add RemoveJob Duties Add RemoveReason for Leaving Add RemoveHigh School Diploma(Required) Yes No year of graduationPlease list any colleges attended and degrees obtained.(Required) Add RemovePERSONAL/PROFESSIONAL REFERENCES (Do not include family members or past supervisors) - Need three references.Name Add RemovePhone Number Add RemoveOccupation Add RemovePLEASE READ CAREFULLY BEFORE DIGITALLY SIGNING THIS APPLICATION I understand that consideration of this application in no way implies a contract of employment. I understand that if an employment relationship is established, I have the right to terminate my employment at any time for any reason. At any time during the first ninety (90) days of my employment, my position may be terminated with compensation paid through the last day worked. I understand that Midwest Eye Associates promotes a drug/alcohol free workplace and agree to abide by the guidelines established in the Policy and Procedure Manual. I understand that as a condition of my employment, I may be required to undergo screening for illegal drugs and hereby give my consent for that testing. My refusal to submit to testing will result in my application being rejected or my employment being terminated. I certify that the answers given in this application are true and accurate to the best of my knowledge. I understand that any false information, misleading statements, or omission of facts is sufficient cause for rejection of my application if Midwest Eye Associates has not employed me and immediate termination if Midwest Eye Associates has employed me. In the event of my employment with Midwest Eye Associates I will comply with all rules, regulations, and policies set forth in the Policy and Procedure Manual or other policies communicated to me. I hereby acknowledge that I have read and understand the preceding statements.Name First Last Date MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone Number(Required)Social Security Number(Required)Date of Birth(Required) MM slash DD slash YYYY Driver's License Number(Required)Email(Required) Are you currently employed?(Required) Yes No May we contact your present employer?(Required) Yes No Have you ever been employed by Midwest Eye Associates in the past?(Required) Yes No Are you legally eligible to work in the United States?(Required) Yes No Are you available to work evenings and Saturdays? Yes No Date you are available to begin work?(Required) Salary requested per hour(Required) Do you speak any languages other than English (list – voluntary answer)(Required) Add RemoveDescribe any specialized training that you feel might better qualify you for this position(Required) RECORD OF EMPLOYMENT: Please list previous employers starting with the most recent. Please give the following information for your last three employers.Nameof Company, Add RemoveCity/State Add RemoveSupervisor Add RemoveDates of Employment Add RemoveEnding Salary Add RemoveJob Duties Add RemoveReason for Leaving Add RemoveHigh School Diploma(Required) Yes No year of graduationPlease list any colleges attended and degrees obtained.(Required) Add RemovePERSONAL/PROFESSIONAL REFERENCES (Do not include family members or past supervisors) - Need three references.Name Add RemovePhone Number Add RemoveOccupation Add RemovePLEASE READ CAREFULLY BEFORE DIGITALLY SIGNING THIS APPLICATION I understand that consideration of this application in no way implies a contract of employment. I understand that if an employment relationship is established, I have the right to terminate my employment at any time for any reason. At any time during the first ninety (90) days of my employment, my position may be terminated with compensation paid through the last day worked. I understand that Midwest Eye Associates promotes a drug/alcohol free workplace and agree to abide by the guidelines established in the Policy and Procedure Manual. I understand that as a condition of my employment, I may be required to undergo screening for illegal drugs and hereby give my consent for that testing. My refusal to submit to testing will result in my application being rejected or my employment being terminated. I certify that the answers given in this application are true and accurate to the best of my knowledge. I understand that any false information, misleading statements, or omission of facts is sufficient cause for rejection of my application if Midwest Eye Associates has not employed me and immediate termination if Midwest Eye Associates has employed me. In the event of my employment with Midwest Eye Associates I will comply with all rules, regulations, and policies set forth in the Policy and Procedure Manual or other policies communicated to me. I hereby acknowledge that I have read and understand the preceding statements.Name First Last Date MM slash DD slash YYYY
