* Required Information
Position Applied For:*
Applicant Telephone:*
Social Security Number:*
Your Name:*
Address:*
Are you able to perform the essential functions of the position with or without accommodations?
Yes No
Are you legally eligible for employment in the USA? (If yes, verification will be required.)
Yes No
I am seeking a permanent position:	Yes No
If necessary for the job I am able to:
Work (which shifts)?
Work overtime?
Provide a valid Alaska Drivers License?
If necessary for the job, are you over (Please mark one)	14 15 16 18 19 21
I will be able to report to work days after being notified that I am hired.
Education
High School
Name
Years Completed
Field of Study
Graduate or Degree
High School
Name
Years Completed
Field of Study
Graduate or Degree
College/University
Name
Years Completed
Field of Study
Graduate or Degree
Business/Technical
Name
Years Completed
Field of Study
Graduate or Degree
Other (May include grammar school)
Name
Years Completed
Field of Study
Graduate or Degree
Military Service:	Yes No
Duty/Specialized Training:
References: List two personal references who are not relatives or former supervisors.
Name
Address
Telephone
Occupation
Years known
Name
Address
Telephone
Occupation
Years known
Employment: List last employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here.
Employer Name
Employer Address
Position Title/Duties Skills
Supervisor's Name
Telephone
Dates Employed	from to
Reason for leaving
Employer Name
Employer Address
Position Title/Duties Skills
Supervisor's Name
Telephone
Dates Employed	from to
Reason for leaving
Employer Name
Employer Address
Position Title/Duties Skills
Supervisor's Name
Telephone
Dates Employed	from to
Reason for leaving
Employer Name
Employer Address
Position Title/Duties Skills
Supervisor's Name
Telephone
Dates Employed	from to
Reason for leaving
Summarize other employment related to this job:
Types of computers, other electronic or mechanical equipment that you are qualified to operate or repair:
Typing speed:	per minute
Professional Licenses, Certifications or Registrations:
Additional skills including supervision skills, other languages, or information regarding the career/occupation you wish to bring to the employer's attention:
In case of accident or illness please contact:
Name:
Daytime phone:
Address:
Relationship:
Information to the applicant: As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references.
If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the US, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms.
I understand and agree to the information shown above:
Signature:*
Date:
Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment
Employer Section: At Vision Healthcare Services Inc, all services are provided, referrals are issued and employment actions are made without regard to race, sex, color, national origin, ancestry, religious creed, handicap or age.
Employer Authorized Rep. Signature
Date