Job Application

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The Company is an equal opportunity employer and considers applications for all positions without regard to race, sex, religion, color, national origin, pregnancy, genetic information for any other characteristic protected by applicable law. Please let us know if you require a reasonable accommodation to complete this 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

    High School Education

    School Name

    City & State of High School

    Years Attended

    Did you graduate?
    YesNo

    College Education

    College Name

    City & State of College

    Years Attended

    Did you graduate?
    YesNo

    Trade, Business or Correspondence School

    School Name

    City & State of School

    Years Attended

    Did you graduate?
    YesNo

    General Information

    Subject of special study/research work

    Special Training

    Special Skills

    US Military or Naval Service

    US Military Rank

    Employment History

    Employer #1

    Company Name

    City

    State

    Phone

    Job Title, Duties and Responsibilities

    Reason for Leaving

    Dates of Employment

    Wage or Salary

    Employer #2

    Company Name

    City

    State

    Phone

    Job Title, Duties and Responsibilities

    Reason for Leaving

    Dates of Employment

    Wage or Salary

    Employer #3

    Company Name

    City

    State

    Phone

    Job Title, Duties and Responsibilities

    Reason for Leaving

    Dates of Employment

    Wage or Salary

    Employer #4

    Company Name

    City

    State

    Phone

    Job Title, Duties and Responsibilities

    Reason for Leaving

    Dates of Employment

    Wage or Salary

    Personal References

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

    Reference #1

    Name

    Title

    Phone

    Email Address

    Nature of your relationship

    Reference #2

    Name

    Title

    Phone

    Email Address

    Nature of your relationship

    Reference #3

    Name

    Title

    Phone

    Email Address

    Nature of your relationship

    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."

    Friendly, Convenient Medical and Optical Vision care Delivered with Excellence

    Deaconess Gateway Health Center

    4233 Gateway Blvd
    Newburgh, IN 47630

    Deaconess Clinic Downtown

    120 SE 4th St
    STE# 1300
    Evansville, IN 47708

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