Application Step 1 of 5 20% Personal InformationYour Name First Middle Last Your Email Address Enter Email Confirm Email Address Street Address City State / Province / Region ZIP / Postal Code Phone NumberWhen is the best time for us to reach you via telephone?MorningsEarly AfternoonLate AfternoonEarly EveningWould you accept full time work? Yes No Would you accept part time work? Yes No Have you ever been employed here? Yes No If yes, date:Are you lawfully authorized to work in the United States? Yes No If you are under 18 years of age, can you furnish a work permit if required? N/A Yes No Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitted by law. Yes No Need more information about job's essential functions to respond. If given an offer how soon after would you be able to start? EducationSchool(include City and State)Years CompletedCompleted Diploma Degree Certification GED Other Major/MinorGPAAdd Another?(Required) Yes No School(include City and State)Years CompletedCompleted Diploma Degree Certification GED Other Major/MinorGPAAdd Another? Yes No School(include City and State)Years CompletedCompleted Diploma Degree Certification GED Other Major/MinorGPA EmploymentEmployerPhoneAddress Street Address City State / Province / Region Job TitleDates Employed (Month and Year)Immediate SupervisorEmail May We Contact? Yes No Later Summarize the type of work preformedAdd Another?(Required) Yes No EmployerPhoneAddress Street Address City State / Province / Region Job TitleDates Employed (Month and Year)Immediate SupervisorEmail May We Contact? Yes No Later Summarize the type of work preformedAdd Another? Yes No EmployerPhoneAddress Street Address City State / Province / Region Job TitleDates Employed (Month and Year)Immediate SupervisorEmail May We Contact? Yes No Later Summarize the type of work preformed Special training or skills that would benefit you in the job for which you are applying:Upload ResumeUpload your resume in .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB.Upload Cover LetterUpload your cover letterin .pdf, .doc or .docx formatAccepted file types: pdf, doc, docx, Max. file size: 25 MB. Applicant Statement(Required)I certify that all the information I have provided in order to apply for and secure work with this employer is true, complete and correct. I expressly authorize, without reservation, the employer, its representatives, employee or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and education institutions and to otherwise verify the accuracy of all information provided by me in the application, resume or job interview. I understand that this employer is an equal opportunity employer and does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. If I am hired; I understand that Paul Phillips Eye and Surgery Center is an "At Will" employer and I am free to resign at any time, with or without cause and with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer's CEO or Human Resources Director. I understand Paul Phillips Eye and Surgery Center is drug free. All offers of employment are contingent on drug screen and background check results. I understand if hired, continued employment is based on compliance with Paul Phillips Eye and Surgery Center's background and alcohol/drug programs which are in accordance with federal, state and local law. I understand that if I am hired, my employment will be subject to a probationary period, which ordinarily will not exceed 90 days from the date I am hired. If I am discharged at any time during the probationary period for unsatisfactory performance, I understand that this employer will not be charged for any unemployment benefits that may be paid to me for work I performed during the probationary period. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. This Company does not tolerate unlawful discrimination in its employment practices. No question on this application is used for the purpose of limiting or excluding an applicant from consideration of employment on the basis of his or her sex, race, color, religion, national origin, genetic information, citizenship, age, disability, sexual orientation or any other protected status under applicable federal, state, or local law. The Company likewise does not tolerate harassment based on sex, race, color, religion, national origin, genetic information, citizenship, age, disability, sexual orientation or any other protected status. Examples of prohibited harassment include, but are not limited to, unwelcome physical contact, offensive gestures, unwelcome comments, jokes, epithets, threats, insults, name-calling, negative stereotyping, possession or display of derogatory pictures or other graphic material, and any other words or conduct that demean, stigmatize, intimidate, or single out a person because of his/her membership in a protected category. Harassment of our employees is strictly prohibited, whether it is committed by a manager, coworker, subordinate, or non-employee (such as vendor or customer). The Company takes all complaints of harassment seriously and all complaints will be investigated promptly and thoroughly. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) eliminate me from further consideration of employment, or (ii) may result in my immediate discharge from the employer's service, whenever it is discovered. DO NOT SELECT THIS BOX UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT. I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.Signature(Required)Date(Required) MM slash DD slash YYYY Δ