GROSSNICKLE EYE CENTER, INC.

Equal Opportunity Employer

PRE-EMPLOYMENT APPLICATION

(Please Print)

PERSONAL INFORMATION
Name:
First Middle Last
Home Address: / Current Phone Numbers:
Daytime: ( )
(Street) (Apt. #) / Evenings: ( )
(City) (State) (ZIP)
Person to Contact in Case of Emergency:
(Name)
(Relationship) (Phone)
Institution / Name & Location / Degree or Certificate / Specialty Areas
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?
WORK INFORMATION: GENERAL
Present Employment Status: / Date available for work:
 / Employed / Specify days and hours for which you are available:
 / Full Time /  / Part Time /  / Temporary
 / Unemployed / Can you work overtime? /  / Yes /  / No
Are you over 18 years of age? /  / 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 / Street Address City, State, Zip / Phone Number
Business / Supervisor’s Name / Date Started / Date Left
Title / Reason for Leaving
Responsibilities / Professional Reference Name / OK to contact now
 Yes  No
Name / Street Address City, State, Zip / Phone Number
Business / Supervisor’s Name / Date Started / Date Left
Title / Reason for Leaving
Responsibilities / Professional Reference Name / OK to contact now
 Yes  No
Name / Street Address City, State, Zip / Phone Number
Business / Supervisor’s Name / Date Started / Date Left
Title / Reason for Leaving
Responsibilities / Professional Reference Name / 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 bebound by my representations and undertakings herein.
Date:______Applicant’s Signature:______

W-02/05, R-7/16

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