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Application for Employment

Please contact Stacy Campbell at 952-924-4038 or scampbell@southdaleeyeclinic.com with any questions.

* : required

Applicant Information

First Name:*M.I.:Last Name:*
Street Address:*Apt/Unit Number:
City:*State:*Zip:*
Phone Number:*Email Address:*
Last 4 Digits of Social Security #:*Desired Salary:
$Date Available:*
Position Applying For:*
Are you authorized to work lawfully in the United States for Southdale Eye Clinic?*
Are you able to lift 50 lbs or more?*
Have you ever worked for this company before?*
When did you previously work for Southdale Eye Clinic?*

Education

High School Name:*High School Address:
Attended From Date:*Attended To Date:*
Did You Graduate?*
College Name:College Address:
Attended From Date:Attended To Date:
Did You Graduate?
What Degree Did You Earn?
Other School Name:Other School Address:
Attended From Date:Attended To Date:
Did You Graduate?
What Degree or Certification Did You Earn?

References

Please list three professional references

1) Full Name:*Relationship:*
Company:*Phone:*
Address:*
2) Full Name:*Relationship:*
Company:*Phone:*
Address:*
3) Full Name:*Relationship:*
Company:Phone:
Address:

Previous Employment

Please list a minimum of two previous employers

Company Name:*Phone:*
Address:*
Job Title:*Supervisor:*
Responsibilities:*
Start Date:*End Date:*
Reason for leaving:*
May we contact this employer for a reference?*
Company Name:*Phone:*
Address:*
Job Title:*Supervisor:*
Responsibilities:*
Start Date:*End Date:*
Reason for leaving:*
May we contact this employer for a reference?*
+ Add Another Previous Employer