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Position Applied For
How did you learn about this position?
If learned from an Employee, Family, Friend, or Other, please specify:

Personal Information


Yes    No
Yes    No
Yes    No

U.S. Military Service

Yes    No

General Information — You must be 16 years of age to be considered for employment.

Are you at least 16 years of age?    Yes   No
If employed and you are 16, can you furnish a work permit?    Yes   No
Have you filed an application here before?    Yes   No
Have you ever been employed here before?    Yes   No
Are you a U.S. citizen?    Yes   No
If your answer is No, are you specifically authorized to be employed in the United States?    Yes   No
If your answer is No, please explain. NOTE: If you are offered employment, you may be asked to provide documentation of your citizenship or work authorization.
Have you ever been arrested for or convicted of a criminal offense other than a minor traffic violation?    Yes   No
If your answer is Yes, please give details including dates, charges, and dispositions.
Is there any information we would need about your name or use of another name for us to be able to check your work record?    Yes   No
If your answer is Yes, please specify.
Are you employed now?    Yes   No
If Yes, may we contact your present employer?    Yes   No
On what date would you be available for work?   
Are you available to work?    Full Time   Part-Time   Temporary
Hours Available — Check all that apply
Mon-Fri   Weekends   Mornings   Afternoons   Evenings
Are you on a lay-off and subject to recall?    Yes   No

Job-Related Information

Do you have a valid driver’s license?    Yes   No
List your last three jobs, beginning with the most recent.

Prior Employment (1)

Still Employed?    Yes   No
Dates Employed    From   To
May we contact this employer?    Yes   No

Prior Employment (2)

Dates Employed    From   To
May we contact this employer?    Yes   No

Prior Employment (3)

Dates Employed    From   To
May we contact this employer?    Yes   No

Please list three personal references, other than prior employers or relatives, whom we can contact.

References (1)

References (2)

References (3)


By signing below, I certify that the answers and information provided on this form are true, accurate, and complete to the best of my knowledge. I understand that if any answer is not true, accurate, or complete, I may not be hired, or if hired, I may be discharged.

I understand that this employer will thoroughly investigate my work and personal history, character, and qualifications and verify all information given on this application, on related papers, and in interviews. Except for those that I have specifically noted on the form, I authorize any firms, individuals, references, and schools named on the form to provide this employer with information regarding my work, educational history, or character and to cooperate fully with the investigation of my character and qualifications. I authorize them to provide any information requested about me and I release them from all liability for damage in providing this information.

I understand that this employer follows an “employment at will” policy, which means that they or I may terminate my employment at any time, and for any reason consistent with applicable state or federal law. I understand that this application is not a contract of employment. I acknowledge that no oral representations have been made. If I am hired, I agree to conform to the rules and expectations provided to me by this employer.

Thank You

Thank you for applying to become a part of the EyeCare Specialties team. We have received your application and will be reviewing all applicants as soon as possible. As the largest independently-owned optometry practice in Nebraska, we look forward to adding talented personnel to our team.

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