EMPLOYMENT APPLICATION

Applicant First Name

Applicant Middle Name

Current Street Address

How were you referred to River Falls Eye Surgery and laser Center?

Employment Positions

Position(s) applying for:

Are you applying for:

Regular full-time work?

Yes No

Regular part-time work?

Yes No

Temporary work – such as summer or holiday work?

Yes No

What days and hours are you available for work?

If applying for temporary work, when will you be available?

If hired, on what date can you start working?

Can you work on the weekends?

Yes No

Can you work evenings?

Yes No

Are you available to work overtime?

Yes No

Personal Information

If hired, would you have transportation to/from work?

Yes No

Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)

Yes No

If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?

Yes No

If hired, are you willing to submit to and pass a controlled substance test?

Yes No

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?

Yes No

If no, describe the functions that cannot be performed:

Education, Training and Experience

Number of years completed:

Did you graduate?

Yes No

Degree / diploma earned

College / University

Number of years completed:

Did you graduate?

Yes No

Degree / diploma earned

Vocational School

Number of years completed:

Did you graduate?

Yes No

Degree / diploma earned

Total Years of Service

Additional Information

Do you speak, write or understand any foreign languages?

Yes No

If yes, list languages(s) and how fluent of a speaker you consider yourself to be.

Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?

Yes No

If yes, please explain:

Are you currently employed?

Yes No

If you are currently employed, may we contact your current employer?

Yes No

Below, please describe past and present employment positions, dating back five (5) years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.

Length of Employment (Include Dates)

May we contact this employer for references?

Yes No

Length of Employment (Include Dates)

May we contact this employer for references?

Yes No

Length of Employment (Include Dates)

May we contact this employer for references?

Yes No

(Attach sheet if more space is needed)

List below three (3) persons who have knowledge of your work performance within the last four (4) years. Please include professional references only.

Number of Years Acquainted

Please read each paragraph, then sign below:

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure employment can be grounds for rejection of application or, if I am employed by River Falls Eye Surgery and Laser Center, terms for my immediate expulsion from River Falls Eye Surgery and Laser Center.

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or River Falls Eye Surgery and Laser Center.

I permit River Falls Eye Surgery and Laser Center to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release River Falls Eye Surgery and Laser Center, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

I understand that River Falls Eye Surgery and Laser Center requires job offered candidates to undergo a criminal background verification. Information obtained from the criminal background verification may be cause for River Falls Eye Surgery and Laser Center to withdraw the employment offer. A copy of the background verification is available upon request.

Applicant's Signature:

Contact

River Falls Eye Surgery & Laser Center

183 E Pomeroy Street

River Falls, WI 54022

(Get Directions)

EMPLOYMENT APPLICATION