Form Employment – Brinton Vision Intake

Full Employment Application for Vision Care Partners, LLC
Welcome to Brinton Vision! Thank you for your interest in joining our team and work family. Before filling out this application please gather the name, current phone, and email for your direct manager and that manager's supervisor for each of the jobs and contract work positions you have held in the past eight years. This application should take about thirty minutes to fill out. We are proud to be an equal opportunity employer.
Legal name*
First Last
Preferred name
Email*
Mobile phone number*
Address*
Street Address City State ZIP Code
How did you hear about this position?*
Who can we thank for mentioning Brinton Vision?
Where else did you hear about Brinton Vision?

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Please list the position(s) for which you are applying*
Why do you want to work for Vision Care Partners?

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Are you currently employed?*
- Yes
- No
For what reasons are you seeking to leave your current place of employment?*
Would you like to indicate your expected pay in hourly or salary terms?*
- Hourly
- Salary
Expected hourly wage*
Please enter a number greater than or equal to 7.25.
Expected annual salary*
Please enter a number greater than or equal to 23660.

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Days and times when you are available to work
For the days Monday through Saturday listed below, indicate the start time and end time of your availability to work in our office for each given day. If you are unavailable to work on a particular day, indicate this by selecting the same starting and ending time for that day.
Please indicate your available hours to work Monday thru Friday
Please indicate your available hours to work Saturdays
Do you have any additional restrictions on your day/time availability to work in our office?*
- Yes
- No
If yes, please explain.*
Additional comments
I affirm that my days and hours of office work availability indicated above are true and correct.*
- I understand and agree
For pre-MD/OD/PA school students applying for the medical/surgical technician position, indicate the approximate date you plan to enter medical, optometry, or PA school.
On what date would you be able to begin work for Vision Care Partners?*

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Education
We require the following details in order to verify information provided on this application.
Did you graduate from high school?*
- Yes
- No
Name of high school, city, and state*
Did you attend college?*
- Yes
- No
Do plan to attend college?*
- Yes
- No

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Name of college, city, and state*
College major and minor, if applicable*
Did you graduate with a college degree or diploma?*
- Yes
- No
Reason for not graduating*
- Still anticipate graduating
- Personal reasons
Did you attend graduate school?*
- Yes
- No
Do you plan to attend graduate school?*
- Yes
- No

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Name of graduate school, city, and state*
Degree sought or focus of studies*
Did you graduate with a graduate degree or diploma?*
- Yes
- No

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Other training/certifications

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Employment History
Please include information for each employment/job position and contractor/1099 position you have held in the past eight years. If you worked in the role for even part of one day, it counts and must be listed. Our company extends employment offers only once we are able to reach your direct manager and that individual's manager, where applicable, for each job you have held in the past eight years. This is an important aspect of protecting our team members, unique culture, and brand. Providing incomplete information (e.g. leaving out a job or contractor position) or false information (e.g. falsifying a month or year on start/end date or title) is taken seriously and may result in discipline, up to and including termination.*
- I understand and agree
How many jobs will you be reporting as per above?*

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Company #1
Company Name - #1 most recent in chronological order*
Address / location*
Start date*
Are you currently employed by or a contractor for this company?*
- Yes, full-time
- Yes, part-time
- No
End date*
Final Position/Title*
Description of your work
Describe a typical week's work schedule, being specific about days and hours*

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Would you like to list your final wage in hourly or salary terms?*
- Hourly
- Salary
Final hourly wage*
Please enter a number greater than or equal to 7.25.
Final annual salary*
Please enter a number greater than or equal to 23660.

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My position was*
- Full time, W2
- Part time, W2
- Contractor, 1099
Reason for conclusion of this employment*
- Voluntarily resigned
- Involuntarily discharged
- Layoff or workforce reduction
Whether voluntary, involuntary, or due to layoff, please provide a detailed explanation for your answer in the previous question*
How many days of notice did you provide to your manager prior to your departure?*

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Name and title of direct manager*
Direct manager's current phone number*
May we contact your direct manager listed above?*
- Yes
- No
If no, please explain*
Was your direct manager the company owner, or did he/she have a supervisor?*
- My manager was the company owner
- My manager had or has a supervisor

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Name and title of your direct manager's supervisor/manager*
This individual's current phone number*
May we contact your direct manager's supervisor/manager listed above?*
- Yes
- No
If no, please explain*

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Company #2
Company Name - #2 most recent in chronological order*
Address / location
Start date*
Are you currently employed by or a contractor for this company?*
- Yes, full-time
- Yes, part-time
- No
End date*
Final Position/Title*
Description of your work
Describe a typical week's work schedule, being specific about days and hours*

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Would you like to list your final wage in hourly or salary terms?*
- Hourly
- Salary
Final hourly wage*
Please enter a number greater than or equal to 7.25.
Final annual salary*
Please enter a number greater than or equal to 23660.

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Name and title of direct manager*
Direct manager's current phone number*
May we contact your direct manager listed above?*
- Yes
- No
If no, please explain*
Was your direct manager the company owner, or did he/she have a supervisor?*
- My manager was the company owner
- My manager had or has a supervisor

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Name and title of your direct manager's supervisor/manager*
This individual's current phone number*
May we contact your direct manager's supervisor/manager listed above?*
- Yes
- No
If no, please explain*

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Company #3
Company Name - #3 most recent in chronological order*
Address / location*
Start date*
Are you currently employed by or a contractor for this company?*
- Yes, full-time
- Yes, part-time
- No
End date*
Final Position/Title*
Description of your work
Describe a typical week's work schedule, being specific about days and hours*

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Would you like to list your final wage in hourly or salary terms?*
- Hourly
- Salary
Final hourly wage*
Please enter a number greater than or equal to 7.25.
Final annual salary*
Please enter a number greater than or equal to 23660.

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At the conclusion of this job my position was*
- Full time, W2
- Part time, W2
- Contractor, 1099
Reason for conclusion of this employment.*
- Voluntarily resigned
- Involuntarily discharged
- Layoff or workforce reduction
Whether voluntary, involuntary, or due to layoff, please provide a detailed explanation for your answer in the previous question*
How many days of notice did you provide to your manager prior to your departure?*

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Name and title of direct manager*
Direct manager's current phone number*
May we contact your direct manager listed above?*
- Yes
- No
If no, please explain
Was your direct manager the company owner, or did he/she have a supervisor?*
- My manager was the company owner
- My manager had or has a supervisor

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Name and title of your direct manager's supervisor/manager
This individual's current phone number
May we contact your direct manager's supervisor/manager listed above?
- Yes
- No
If no, please explain

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Company #4
Company Name - #4 most recent in chronological order*
Start date*
Are you currently employed by or a contractor for this company?*
- Yes, full-time
- Yes, part-time
- No
End date*
Final Position/Title*
Description of your work
Describe a typical week's work schedule, being specific about days and hours*

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Would you like to list your final wage in hourly or salary terms?*
- Hourly
- Salary
Final hourly wage*
Please enter a number greater than or equal to 7.25.
Final annual salary*
Please enter a number greater than or equal to 23660.

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At the conclusion of this job my position was*
- Full time, W2
- Part time, W2
- Contractor, 1099
Reason for conclusion of this employment.*
- Voluntarily resigned
- Involuntarily discharged
- Layoff or workforce reduction
Whether voluntary, involuntary, or due to layoff, please provide a detailed explanation for your answer in the previous question*
How many days of notice did you provide to your manager prior to your departure?*

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Name and title of direct manager*
Direct manager's current phone number*
May we contact your direct manager listed above?*
- Yes
- No
If no, please explain*
Was your direct manager the company owner, or did he/she have a supervisor?*
- My manager was the company owner
- My manager had or has a supervisor

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Name and title of your direct manager's supervisor/manager
This individual's current phone number
May we contact your direct manager's supervisor/manager listed above?*
- Yes
- No
If no, please explain

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Company #5
Company Name - #5 most recent in chronological order*
Start date*
Are you currently employed by or a contractor for this company?*
- Yes, full-time
- Yes, part-time
- No
End date*
Final Position/Title*
Description of your work
Describe a typical week's work schedule, being specific about days and hours*

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Would you like to list your final wage in hourly or salary terms?*
- Hourly
- Salary
Final hourly wage*
Please enter a number greater than or equal to 7.25.
Final annual salary*
Please enter a number greater than or equal to 23660.

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At the conclusion of this job my position was*
- Full time, W2
- Part time, W2
- Contractor, 1099
Reason for conclusion of this employment.*
- Voluntarily resigned
- Involuntarily discharged
- Layoff or workforce reduction
Whether voluntary, involuntary, or due to layoff, please provide a detailed explanation for your answer in the previous question*
How many days of notice did you provide to your manager prior to your departure?*

Save and Continue Later

Name and title of direct manager*
Direct manager's current phone number*
May we contact your direct manager listed above?*
- Yes
- No
If no, please explain*
Was your direct manager the company owner, or did he/she have a supervisor?*
- My manager was the company owner
- My manager had or has a supervisor

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Name and title of your direct manager's supervisor/manager*
This individual's current phone number*
May we contact your direct manager's supervisor/manager listed above?*
- Yes
- No
If no, please explain*

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Have you ever written comments in a public forum, including on social media, that are critical of a current or former work colleague, manager, or employer?*
- Yes
- No
Have you ever quit a job without giving two weeks' notice?*
- Yes
- No
Comments

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APPLICANT’S ACKNOWLEDGMENTS, REPRESENTATIONS, AUTHORIZATIONS, AND AGREEMENTS As an applicant for position with Vision Care Partners LLC (“VCP”), you need to understand and agree to several things about the application process and employment with VCP, if you are hired.
FIRST, for the protection of our patients, as a medical and surgical facility, our office is required to uphold high standards of cleanliness and sterility. We do not allow animals or pets of any kind into our facility, including comfort animals. All employees must practice high standards of personal hygiene. All employees are required to obtain an annual flu shot at the beginning of the flu season and follow all designated requirements to prevent the spread of any contagious disease, including Covid19. All employees are required to verify that they are up-to-date on vaccinations as recommended by health officials. An employee seeking exemption from the vaccination requirements as a result of disability, medical contraindication or sincerely-held religious belief is required to provide reasonable documentation from a licensed physician or other authorized individual requesting that the employee be exempted from the requirement(s) due to disability, medical contraindication to the subject vaccination, or sincerely-held religious belief, and detailing the basis for the requested exemption. We will consider all exemption requests on a case-by-case basis and will comply with state and federal law. We reserve the right to require an employee seeking an exemption to follow alternative disease transmission prevention protocols, including, but not limited to, wearing of masks and other personal protective equipment, limiting hours and roles within the business, and potential suspension of contact with patients or other employees.*
- I understand and agree
SECOND, VCP follows an employment-at-will policy. I understand and agree that I or VCP may terminate the employment relationship at any time, for any reason, or for no reason, consistent with applicable state or federal law. I understand and agree that the employment at will status cannot be changed, verbally or in writing, unless the change is specifically authorized by a written document signed by a member-manager of this company. I understand and agree that my application for employment is not a contract for employment. I understand and agree that my application for employment shall remain active and valid for a period of three months. After that time, if I wish to be considered for employment, I must submit a new application. I understand that federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity. Failure to submit such proof will result in denial of employment.*
- I understand and agree
THIRD, I represent, warrant, and certify that all information and statements contained in my written application for employment, in interviews or other conversations or written communications concerning potential employment as well as throughout my employment with VCP ("Information and Statements"), if I am hired, are true, accurate, complete, and correct. I understand and agree that any employment with VCP is based upon the accuracy and completeness of all such information. I acknowledge and affirm that this information will be relied upon by VCP in determining my competencies and qualifications to act as a prospective employee. I understand and agree that any misstatement, omission, incomplete, or any inaccurate information provided to VCP during the application process or during employment, if hired, is grounds for denying employment, termination of employment, if hired, and money damages. If anything about these Information and Statements changes, I will notify VCP immediately of those changes.*
- I understand and agree
FOURTH, VCP, in connection with the hiring process and during my employment, if hired, may make, from time to time, as VCP deems appropriate, a thorough background check and other inquiries relating to, among others, my character, education, social media activities, lawsuits, employment history, workplace actions, skills, work performance, experience, reasons for termination of past employment, work related injuries, driving record, salary history, credit history, civil law filings, and criminal records. These inquiries and checks may be obtained from previous employers, public records, and any other source. (Confidential information received will be maintained and used only by persons who have a need to know.) I hereby authorize all entities and persons, including law enforcement agencies, educational institutions, information service bureaus, former employers, schools, reference or insurance companies to provide such information to VCP. In addition, I hereby release all such entities and persons from any and all claims that I may have, now or in the future, arising out of such entities and persons’ providing information to VCP.*
- I understand and agree
My e-signature above shall constitute my actual signature on this document. By typing my name in the box above I certify that the information provided, and representations made herein are true and correct. I also give my permission to use all such information for purposes relating to my pre-hiring process and, if hired, relating to my employment.*
Today's Date*
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Step 1 of 40

Full Employment Application for Vision Care Partners, LLC

Days and times when you are available to work

Education

Employment History

Company #1

Self-awareness

Company #2

Company #3

Company #4

Company #5