Oculoplastics - Dayton, OH

First Name, Last Name, Email, Phone, Resume/CV, Cover Letter

• Are you eligible to work in the U.S.? choose one
• Have you obtained a High School Diploma or GED? choose one
• What is your desired compensation for this role?
• Do you currently hold any of these certifications/licenses? Please check all that apply. If not, please select NONE. choose any
• Have you ever been terminated from employment or asked to resign by an employer? choose one
• If yes, please provide company name and details. written answer
• Can you work any shift? choose one
• Can you work overtime, including weekends? choose one
• Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? choose one
• Were you referred by a current employee? choose one
• If referred by a current employee, what is their full name? written answer
• If you accept employment with our company, will you live or work in the state of IL? choose one
• To the best of your knowledge, have you ever worked for our company or affiliated companies? choose one
• EyeCare Partners and it's affiliated companies are an equal opportunity employer. EyeCare Partners does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for EyeCare Partners to hire me. If I am hired, I understand that either EyeCare Partners or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of EyeCare Partners has the authority to make any assurance to the contrary. I attest with my typed signature below that I have given to EyeCare Partners true and complete information on this application. No requested information has been concealed. I authorize EyeCare Partners to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. Signature:
• I attest that I am not an “Ineligible Person” and that I understand that I must immediately disclose to EyeCare Partners any debarment, exclusion, or suspension. Ineligible Persons includes an individual or entity who is currently excluded, debarred, suspended, or otherwise ineligible to participate in the Federal health care programs or in Federal procurement or non procurement programs; or has been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a‐7(a), but has not yet been excluded, debarred, or suspended. Signature: