EPI Employment Application

Eyes Plus is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or sheshould contact a company representative.

Please complete all of the sections below:

Full Name:*

First NameLast Name

Today's Date:*

Date

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Best Email*

example@example.com

YESNO

EDUCATION & TRAINING*

Rows	Type of Study	Name/Location (City, State)	# of Year(s) Completed & Year Graduated	Type of Degree/ Diploma Earned
High School
College/ University
Technical/ Vocational
Other

1. Name/ Address/ Phone of Company/Employer *

Your Job Title/ Your Supervisor Name*

Date Started*

Date

Date Ended*

Date

Starting Pay*

Ending Pay*

Reason(s) for Separation*

2. Name/ Address/ Phone of Company/Employer

Your Job Title/ Your Supervisor Name

Date Started

Date

Date Ended

Date

Starting Pay

Ending Pay

Reason(s) for Separation

3. Name/ Address/ Phone of Company/Employer

Your Job Title/ Your Supervisor Name

Date Started

Date

Date Ended

Date

Starting Pay

Ending Pay

Reason(s) for Separation

4. Name/ Address/ Phone of Company/Employer

Your Job Title/ Your Supervisor Name

Date Started

Date

Date Ended

Date

Starting Pay

Ending Pay

Reason(s) for Separation

YESNO

How were you referred to our organization? (i.e. ‘Indeed’, posted sign, website, FB, relative, etc.)*

What information should we know about that would pertain to the position being applied for? (i.e. schedule accommodations, health restrictions/needs, special needs, scheduling or duty restrictions, transportation, etc.) Please specify

Branch of Service

Rank & Type of Service

Training/Experience Received that would be an asset for this position

References*

Rows	Name	Occupation	Yrs. Known	Address	Phone
#1
#2
#3

LIST DAYS AND HOURS/TIMES YOU ARE “NOT” AVAILABLE: (*Note: job involves flexibility, but has a consistent schedule of Mon-Wed & Fri-Sat)

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Hours

YESNO

What makes you the “right fit” for this position?*

What are you looking for in a job?*

What 1 word would a co-worker say best describes you and why?*

1. Are you looking for a long-term career and grow with us or a short-term position to gain skills and experience? 2. Do you prefer Full-time or Part-time Position?*

Please list dates and times over the next week that you could be available for phone and in-person interviews:*

Please list any additional information, such as skills, talents, licenses and/or professional degrees that you consider important for the job to which you have applied:

Eyes Plus Incorporated complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.

Please upload your Resume and any other documents pertaining to the application for this position: (i.e. cover Letter, references, skill set list, etc.)*

I understand that Eyes Plus Incorporated follows an employment-at-will policy, in that I or the employer may terminate my employment any time or for any reason, with or without cause, with or without notice, consistent with applicable state or federal law. I understand that my employment is “at will”, and thatI acknowledge that no oral or written statements or representations regarding my employment can alter my at-will employment status, except for a written statement signed by me and either the employer’s Vice-President/Operations Manager or the Company’s President.

I understand that to be employed I must be lawfullyauthorized to work in the United States, and I mustshow the employer documents that will prove that if I am offered the job.

I understand that the company will thoroughly investigate my work and personal history and verify all data given on the application, on related papers, and in interviews. I authorize all individuals, schools, firms named within to provide any information requested about me, and I release them from all liability fordamage in providing this information.

I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.

Full Name*

First NameLast Name

Applicant Signature*

Today's Date*

Date

EYES PLUS, INC. “An Equal Opportunity Employer” DR. HANK MAKINI

1049 KAKALA ST.#102, KAPOLEI, HI 96707 EYESPLUSINC.COM (808) 674-0744

Employment Application

Optometric Assistant & Technician

PREVIOUS & CURRENT EMPLOYMENT

U.S. MILITARY SERVICE

REFERENCES

Resume

AT-WILL EMPLOYMENT: