Grossnickle-Pre-Employment-Application-Form

GROSSNICKLE EYE CENTER, INC Equal Opportunity Employer PRE-EMPLOYMENT APPLICATION (Please Print) PERSONAL INFORMATION Name: First Middle Last (Street) (Apt #) (State) (ZIP) Current Phone Numbers: Daytime: ( ) Home Address: Evenings: (City) ( ) Person to Contact in Case of Emergency: (Name) (Relationship) Institution (Phone) Degree or Certificate Name & Location HIGH SCHOOL G.E.D VOCATIONAL OR TRADE SCHOOL COLLEGE GRADUATE SCHOOL UNITED STATES ARMED FORCES OTHER Of which job-related technical, professional, trade or other organizations are you a member? W-02/05, R-7/16 /storage1/vhost/convert.123doc.vn/data_temp/document/rvh1666215649-5876279-16662156495355/rvh1666215649.doc Specialty Areas WORK INFORMATION: GENERAL Present Employment Status: Employed Full Time Part Time Unemployed Are you over 18 years of age? Date available for work: Specify days and hours for which you are available: Temporary Can you work overtime? Yes No Yes No If not, are you able to furnish any required work permit? Yes No Are you authorized to work in the United States? Yes No If you are a resident alien, give your alien number on your Alien Registration Receipt Card (INS Form 1-151 or I-551): _ Have you ever been convicted of a felony criminal offense? Yes No If yes, please explain: _ Do you currently use any illegal drugs? Yes No If yes, please explain: _ What has been your most enjoyable work (in any job you’ve) held? Explain: _ _ Have you ever worked here before? Yes No If yes, specify: _ Have you ever applied for a job here? Yes No If yes, specify: _ WORK BACKGROUND Please list last three previous employers Name Business Street Address City, State, Zip Supervisor’s Name Date Started Title Reason for Leaving Responsibilities Professional Reference Name Name Business Street Address City, State, Zip Supervisor’s Name Date Started Title Reason for Leaving Responsibilities Professional Reference Name Name Business Street Address City, State, Zip Supervisor’s Name Date Started Title Reason for Leaving Responsibilities Professional Reference Name W-02/05, R-7/16 /storage1/vhost/convert.123doc.vn/data_temp/document/rvh1666215649-5876279-16662156495355/rvh1666215649.doc Phone Number Date Left OK to contact now Yes No Phone Number Date Left OK to contact now Yes No Phone Number Date Left OK to contact now Yes No JOB-RELATED INFORMATION NOTE: Before completing the following part, applicants should first determine the position you are applying for and should then consult the Company’s description of some of the essential functions that bear a demonstrable relationship to successful job performance for each category of job For which job category or position are you applying? If more than one, list them in order of preference _ _ _ Is there anything, with or without reasonable accommodation, that would prevent you from performing the essential functions of the position or positions for which you are applying? If so, explain: _ _ _ REFERENCES Please list names of references (not relatives) (1) Name _ Phone ( ) _ Email _ (2) Name _ Phone ( ) _ Email (3) Name _ Phone ( ) _ Email SIGNATURE AND DISCLAIMER INITIAL Please read the following paragraphs and then sign this Pre-Employment Application after you are sure that the information is correct and complete _ I represent that the information I have given is correct and complete, to the best of my knowledge; that I have not withheld any information that a reasonable person would consider important; and that any misrepresentation or withholding of such acts, whether revealed before or after employment, will constitute cause for elimination from further consideration of this Application or even for dismissal if I have already been employed _ I understand that nothing in this Pre-Employment Application nor anything said to me by any company official or representative during an interview, or anything said to me orally or relied upon by me even after employment, is intended to create any contract of employment or other employment rights No promises regarding employment have been made to me, either to induce me to leave or to reject other employment, to relocate, or in any other respect, and I understand that any such oral promises or representative are against company policy, are unauthorized, and unenforceable _ Any offer of employment shall be valid only if in writing and signed by a company officer Any resulting employment relationship shall be terminable at will, by me or by the company, and any employment rights that go beyond those that are terminable at will, shall only be valid if embodied in a written employment contract that is identified as such and signed by a company official _ I authorize the company to investigate all statements made or information contained in this Pre-Employment Application, and I hereby specifically authorize any persons listed as a reference, any educational institution, the U.S military, or any former employer or supervisor to provide all information requested by the company, without further authorization from me To induce such persons to feel free to communicate with the company, I hereby release any such giver of information from any liability concerning information given about my education, my employment, or my character, whether accurate or not and regardless of mistake, negligence, or possible personal bias against me _ I represent to the company that I am bound by no employment contracts of non-competition agreements that would be breached by any employment that might be offered to me by the company, nor am I in possession of nor will I at any time reveal to the company, under any circumstances, any proprietary or confidential information that is the subject of any contract, non-disclosure agreement, or prior work relationship involving any other person or company I have read this Pre-Employment Application, and, by signing below: I agree to be bound by my representations and undertakings herein W-02/05, R-7/16 /storage1/vhost/convert.123doc.vn/data_temp/document/rvh1666215649-5876279-16662156495355/rvh1666215649.doc Date: Applicant’s Signature: _ W-02/05, R-7/16 /storage1/vhost/convert.123doc.vn/data_temp/document/rvh1666215649-5876279-16662156495355/rvh1666215649.doc