Application for Employment
JURY, FARRAR & ASSOCIATES
DOCTORS OF OPTOMETRY, PA

Pre-Employment Questionnaire
Equal Opportunity Employer

PERSONAL INFORMATION
Name *
Last, First, Middle, Maiden
Your answer
Present Address *
Your answer
Telephone *
Your answer
If under 18, please list current age:
Your answer
EMPLOYMENT DESIRED
Position applied for *
Your answer
Salary desired *
Please be specific.
Your answer
Days available *
Required
How many hours can you work weekly? *
Your answer
Can you work nights? *
Required
Employment desired *
What date can you start? *
Your answer
EDUCATION HISTORY
Educational History *
Please list all educational history, including a list of schools attended (name + address), # of years completed, and any major/degree.
Your answer
GENERAL INFORMATION
Office Skills *
Please check any skills you have.
Required
Please describe any subjects of special study/research and work or special training/skills *
Your answer
Have you ever been in the Armed Forces? *
Are you now a member of the National Guard? *
Military History
Please list your specialty, date entered, and discharge date as appropriate.
Your answer
Additional Information
Please summarize any additional information necessary to describe your qualifications for the specific position you are applying for.
Your answer
FORMER EMPLOYERS
Work Experience *
Please provide a list of work experience from most recent to least recent for the last 5 years. Please include employer address, name of supervisor, dates of employment, salary, title, and reason for leaving.
Your answer
REFERENCES
References *
Please list two references other than relatives or friends.
Your answer
May we contact your current employer? *
AUTHORIZATION
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 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 the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company 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.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

I have read the Authorization statement. *
Did you complete this application yourself? *
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