Children Vision Assessment Score Louetta Application for Employment PRE-EMPLOYMENT QUESTIONNAIRE - AN EQUAL OPPORTUNITY EMPLOYER This application MUST be filled out completely even if a resume is attached. Date MM slash DD slash YYYY Name Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Suffix Present Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberAre you 18 years or older? Yes No Employment DesiredPositionDate You Can Start MM slash DD slash YYYY Salary DesiredWe Hire Full Time ONLY. Is this OK? Yes No Are you employed now? Yes No If so, may we inquire of your present employer? Yes No Have you ever applied to this company before? Yes No Where?When?EducationGrammar School:Name and LocationYears AttendedDid You Graduate? Yes No Subjects StudiedHigh School:Name and LocationYears AttendedDid You Graduate? Yes No Subjects StudiedCollege:Name and LocationYears AttendedDid You Graduate? Yes No Subjects StudiedTrade, Business or Correspondence:Name and LocationYears AttendedDid You Graduate? Yes No Subjects StudiedFormer EmployersList four employers below, starting with the most recent.From MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of EmployerPhone NumberSalaryPositionReason For LeavingFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of EmployerPhone NumberSalaryPositionReason For LeavingFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of EmployerPhone NumberSalaryPositionReason For LeavingFrom MM slash DD slash YYYY To MM slash DD slash YYYY Name and Address of EmployerPhone NumberSalaryPositionReason For Leaving**Have you ever been convicted of a felony or misdemeanor within the last 5 years? Yes No Please Describe**You will not be denied employment solely because of a conviction record, unless the offense is related to the job for which you have applied. Skills/ExperiencePlease check all applicable.General Receptionist or phone answering Sales Cashiering Familiar with computers i.e. Windows Typing Please enter WPMOptical Use Lensometer to read Eyeglasses (SV, Bifocals, Progressives, etc.) Edge Lenses Adjust and Dispense Frames Familiar with LASIK Set Phoropter Operate an Auto-Refractor Perform Prelim Administer Dilation Drops Perform Visual Fields Perform Acuities Insertion and Removal Teaching for Soft Contacts or Gas Perm Contacts ReferencesGive the names of three persons not related to you, whom you have known at least one yearName First Last Address & Phone NumberBusinessYears AquaintedName First Last Address & Phone NumberBusinessYears AquaintedName First Last Address & Phone NumberBusinessYears AquaintedPhysical RecordDo you have any physical limitations that preclude you from performing any work for which you are being considered? Yes No If yes, what can be done to accommodate your limitation?In Case of Emergency NotifyName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberI CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD OF AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE.I agree to the above Yes No Date MM slash DD slash YYYY For Internal Use OnlyDo not fill in below this line.Interviewed byDate MM slash DD slash YYYY Hired Yes No PositionSalary/WageDate Reporting to Work MM slash DD slash YYYY Δ
