Employment Application

1. Employer Information

Employer:	Schroeder Optical Co. Inc.
Address:	1845 Westland Rd SW
City/State/ZIP:	Roanoke, Virginia 24018
Telephone:	540-345-6736

It is the policy of Schroeder Optical Co. Inc. to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.

2. Applicant Information

Applicant Full Name(Required)

Email(Required)

Address(Required)

Home Address*(Required)

Number of years at this address

Daytime Phone

Evening Phone

Mobile Phone(Required)

3. Emergency Contact

Contact Name

Relationship to you

Address(Required)

Daytime Phone

Evening Phone

4. Job Position Applied For

Position(Required)

Employment Type:(Required)

Full time

Part time

5. Salary Desired

Amount ($)(Required)

Per (hour/year)(Required)

6. Referral

Who referred you to our company?(Required)

Do you have any friends or relatives who work here? If yes, please list(Required)

7. Previous Application

Have you applied to our company previously?(Required)

Yes

If yes, when?

8. Availability

If you are offered employment, when would you be available to begin work?(Required)

9. Applicant's Skills

List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and rate your ability (1 = poor, 5 = excellent).

Skill 1(Required)

Years of Experience(Required)

Rating (1-5)(Required)

Skill 3

Years of Experience

Rating (1-5)

Skill 3

Years of Experience

Rating (1-5)

Skill 4

Years of Experience

Rating (1-5)

Skill 5

Years of Experience

Rating (1-5)

10. Applicant Employment History

List your current or most recent employment first. Please list all jobs (including self-employment) you have held, beginning with the most recent, and list and explain any gaps in employment.

Employer Name(Required)

Supervisor Name(Required)

Address(Required)

Job Duties(Required)

Reason for Leaving(Required)

Dates of Employment (Month/Year)(Required)

Employer Name

Supervisor Name

Address

Job Duties

Reason for Leaving

Dates of Employment (Month/Year)

11. Applicant's Education and Training

College/University(Required)

Did you receive a degree?(Required)

Yes

If yes, degree(s) received

High School/GED

Did you receive a degree?(Required)

Yes

Other Training (graduate, technical, vocational)

Professional Licenses or Certifications

Awards, Honors, Special Achievements

12. References

List any two non-relatives who would be willing to provide a reference for you.

Name(Required)

Address(Required)

Telephone(Required)

Relationship

Name(Required)

Address(Required)

Telephone(Required)

Relationship

13. Additional Information

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer.

Additional information

Certification

I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Schroeder Optical Co. Inc. to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I or my employer will be able to terminate the employment relationship at any time and without cause.

I have carefully read the above certification and I understand and agree to its terms.(Required)

I have carefully read the above certification and I understand and agree to its terms.

Applicant Signature(Required)