Online Employment Application Form Doctors of Optometry interested in an association with our group, please contact Dr. Carlson directly at email@example.com Online Employment Application "*" indicates required fields Dr Torrey J Carlson & Associates is an equal opportunity employer. All applicants and employees are considered for employment, disability, marital status, veteran’s status or other protected status under State of Federal law. Please complete this employment application in its entirety even if a resume is provided.Personal DataName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Social Security Number Phone* Email Please provide us your email address.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position DesiredSalary DesiredDate Available* MM slash DD slash YYYY Are you willing to travel between our offices when needed? Yes No Type of employment you are seeking Full Time Part time Temp Of hours desired What days are you available to work on a regular basis? How were you referred to us? Are you eligible to work in the United States? Yes No Are you under 18 years of age? Yes No Is any additional information relative to change of name, use of an assumed nickname necessary to enable us to check on your work record? Yes No If yes, please explain Have you ever been convicted of a crime other than a minor traffic offense, which has not yet been removed from your records by expungement, pardon, or other legal process? Yes No If yes, explain offense and final disposition for each conviction Educational SkillsSchool NameArea of StudyGraduated? Y/NIf yes, type of degreeIf no, how many yrs Add RemoveLicenses (if applicable) Type Office Skills Typing (WPM) Office Works Word Excel Internet Other software/office skills What skills do you have that would make you a desirable candidate for employment in an optometric office?ReferencesPlease list three (3) school, business, or personal references that you give permission for us to contact. They should not be related to you.NameTelephoneKnown How LongType of Reference (Ex:Work/School) Add RemoveWork ExperiencePlease describe your previous work experiancesCompany name, Possition, Dates Employed, Starting Wage, Ending, Supervisor(s), Supervisor Telephone, Responsibilities, Reason For Leaving?May we contact with the componies? Yes No Have you ever been discharged from any job? Yes No Please Explain SignatureDate MM slash DD slash YYYY Consent* I attest to the fact that all of the above information is correct to the best of my knowledge.*EmailThis field is for validation purposes and should be left unchanged.