Job Application

Personal Information

First Name*

Last Name*

Phone*

Email Address*

Referred By

Current Address

Current Address*

Current City*

Current State*

Current Zip*

Previous Address

Previous Address*

Previous City*

Previous State*

Previous Zip*

Employment Desired

What position would you like to apply for?*
Customer ServiceRepOpticalClinicalDiagnostic

Date you can start*

Desired Salary*

Are you employed now? YesNo

If so, may we contact your present employer?
YesNo

Are you legally authorized to working in the US?
YesNo

Have you ever applied with this company before?
YesNo

If so, where?

If so, when?

Education History

Employment History

Personal References

Please list former supervisors and or associates who are acquainted with your employment qualifications.

Special Skills, Abilities, Affiliations

Tell us about any special job related skills and qualifications acquired from employment or other experience that you think are important. Also use this space to tell us about your personal interests and other information you believe will assist us in evaluating your qualifications.

Upload Your Resume

*if applicable

Certification and Agreement

By clicking submit below, you agree to the following: "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."