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Employment Application

APPLICANT INFORMATION

Last Name:
First Name:
MI:
Date:
Apartment / Unit #:
Home Address:
Position Applied for:
City:
State:
Zip:
Home Phone:
Cell:
E-mail:
Date Available:
Desired Salary:
Are you a citizen of the United States? YesNo
If no, are you authorized to work in the U.S.? YesNo
Have you ever worked for this company? YesNo
If so, when?
Have you ever been convicted of a felony? YesNo
If yes, explain
How did you hear about us? Employee Referral
If so, who?
College Placement ServiceCompany WebsiteInternet Job BoardNewspaperStaffing AgencyState Employment OfficeWalk InWord of Mouth – External ReferralOther

WORK HISTORY

Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary $
Ending Salary $
Responsibilities:
From:
To:
Reason for Leaving
May we contact your previous supervisor for a reference? YesNo
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary $
Ending Salary $
Responsibilities:
From:
To:
Reason for Leaving
May we contact your previous supervisor for a reference? YesNo
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary $
Ending Salary $
Responsibilities:
From:
To:
Reason for Leaving
May we contact your previous supervisor for a reference? YesNo

REFERENCES

Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:

EDUCATION

High School:
Address:
From:
To:
Did you graduate? YesNo
Degree:
College School:
Address:
From:
To:
Did you graduate? YesNo
Degree:
Other:
Address:
From:
To:
Did you graduate? YesNo
Degree:

MILITARY SERVICE

Branch:
From:
To:
Rank at Discharge:
Type of Discharge
If other than honorable, explain

DISCLAIMER AND SIGNATURE

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application or during an interview shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references and employers 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 Wing Eyecare from all liability for any damage that may result from utilization of such information.
I also understand and agree that no representative of Wing Eyecare has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

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