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Eyemart Express

Application for Employment

First Name:
Last Name:
Home Phone (XXX-XXX-XXXX):
Cell Phone (XXX-XXX-XXXX):
Email Address:
Street Address:
City, State, Zip:, ,
How did you hear about this position?

Employment Desired
(Must be at least 18 for lab positions)

Position Applying For:
Hourly Rate Desired (per hour):
Date Available to Start (MM/DD/YYYY):
Employment Desired:
Do you have experience in any of the
following?
Have you ever been employed at
Eyemart Express, Vision 4 Less, Visionmart Express or Eyewear Express before?		 Yes No
If yes to the question above, list dates/position/location/reason for leaving below:
Do you currently have any relatives that work for Eyemart Express, Vision 4 Less, Visionmart Express or Eyewear Express? Yes No
If yes to the question above, list their name(s) and relationship(s)?
Please upload your resume here:
(this field only accepts files with the extensions of doc, docx, txt, and rtf)

Education and Military Experience

High School/Trade School:
Name and Location:
Years Completed:
Did You Graduate?YesNo
Major Course of Study:
College
Name and Location:
Years Completed:
Did You Graduate?YesNo
Major Course of Study:
Military Service
Branch:
Highest Rank Held:
From (MM/DD/YYYY):
To: (MM/DD/YYYY):

Former Employers
(Start with your most recent employer first)

From (MM/DD/YYYY):
To (MM/DD/YYYY):
Employer Name/Address:
Salary:
Position:
Reason for Leaving:
From (MM/DD/YYYY):
To (MM/DD/YYYY):
Employer Name/Address:
Salary:
Position:
Reason for Leaving:
From (MM/DD/YYYY):
To (MM/DD/YYYY):
Employer Name/Address:
Salary:
Position:
Reason for Leaving:

Personal References
(List at least one former supervisor or manager)

Name:
Employer:
Relationship:
Daytime Phone:
Name:
Employer:
Relationship:
Daytime Phone:
Name:
Employer:
Relationship:
Daytime Phone:
Can you perform the essential functions of the job you are applying for, with or without reasonable accommodations?
Yes No
In the space provided below, please provide any relevant information.
Have you ever been convicted of a felony or misdemeanor
(other than a moving violation)?
(For the purposes of this question, a "conviction" means: Received a sentence for; a plea of no "no contest"; placed on probation; fined; deferred adjudication withheld.) (ILLINOIS RESIDENTS ONLY: Applicants are not required to report any convictions that have been sealed, expunged, impounded or statutorily eradicated).
YesNo
Any criminal record not disclosed by you may be considered falseification of this application, which may result in revocation of your employment offer or termination of your employment. Answering "yes" to this question is not an automatic dismissal of consideration for employment.
If yes, describe the details of the conviction or other disposition of the charge and the date of the offense in the space provided below.
Please read carefully before submitting: "I certify that all information on this employment application is true and complete. I understand that any false information or omission may disqualify me from consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, current or past employer and school or organization to provide relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements."
Digital Certification Signature:
Digital Certification Date
Signed (MM/DD/YYYY):
 

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