Answer each question fully and accurately. If you need additional space, please continue your answer(s) on the additional space given at the end. No action can be taken on this application until all questions have been answered.

List names of employers in consecutive order with present or last employer first . If self-employed, give firm name and supply business references. If you worked in any of the positions under another name, please give name(s). PLEASE LIST MONTH AND YEAR EMPLOYED. DO NOT LEAVE BLANK.

Please provide professional licenses/certifications held and list any specialized training that may help you perform this job. Include license number and expiration date.

Give three references, not relatives or former employers, who could comment on your abilities to perform the job you seek.

I certify that, to the best of my knowledge, the information contained in this application is true and complete. I understand that my employment may be denied or terminated if I provide false, misleading, or incomplete information during the hiring process or my employment.

I understand that if I am hired, I must produce applicable documents confirming my identity and showing that I am lawfully authorized to work in the United States, in accordance with the Immigration Reform and Control Act of 1986, as amended.

I understand and agree that my prior employers, educational institutions, Eye Care Physicians & Surgeons (ECPS), and other references, listed or not listed on this application, may be contacted by Eye Care Physicians & Surgeons (ECPS). These references are authorized to give ECPS any and all pertinent information they may have. I release all persons or entities involved, including ECPS, from all liability arising from this contact and provision of information.

I agree to submit to any post-offer, pre-employment testing or physicals, as required by ECPS.

I authorize ECPS to conduct a credit history check (if applicable to job) and a criminal history check, and understand that unexpunged criminal convictions may be considered by ECPS in making hiring decisions.

I agree to conform to all ECPS’s policies, rules, and procedures.

Furthermore, I understand and agree that nothing contained in this employment application, the granting of an interview, or in the offer of employment creates a contract for employment between Eye Care Physicians & Surgeons and myself. If an employment relationship is established, I understand that, unless specifically limited in an express, formally executed contract, I have the right to terminate my employment at any time and for any reason and ECPS has the same right.