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Employment ApplicationJosh2022-11-04T18:38:23+00:00

Employment Application Form

"*" indicates required fields

Name*

First Last

Home Phone

Mobile Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Are you legally entitled to work in the United States?*

Yes

No

Are you 18 years of age or older?*

Yes

No

Have you ever been convicted of a misdemeanor or felony or have felony charges pending against you?*

Yes

No

If yes, please provide nature of crime

Languages Spoken:*

Education

High School

Name of School*

Location*

Did you graduate?*

Yes

No

Trade School or College

Name of School

Location

Did you graduate?

Yes

No

Area of Study/ Degree Earned:

Employment History

Beginning with your most recent employment, please give the following information:

Employer*

Job Title*

Address*

Street Address Address Line 2 City State ZIP Code

Supervisor*

Dates of Employment:*

Salary

Duties*

Phone*

Email*

Reason for leaving, if not still employed:*

Are you still employed here?*

Yes

No

May we contact this employer?*

Yes

No

Employment History 2

Employer

Job Title

Address

Street Address Address Line 2 City State ZIP Code

Supervisor

Dates of Employment:

Salary

Duties

Phone

Email

Reason for leaving, if not still employed:

Are you still employed here?

Yes

No

May we contact this employer?

Yes

No

Additional Qualifications

Please describe any other training, education, skills, or achievements that you feel should be considered.

Desired Salary:*

Consent & Signature

Please Read Carefully*

I understand that if I am hired, my employment will be "at-will." My employment may be terminated - or I may resign - at any time, with or without cause. I have carefully completed this application form, and I verify that all the information that I have provided is accurate.

I Agree

CONSENT FOR RELEASE OF EMPLOYMENT INFORMATION*

I have applied for employment at Venice Retina. I authorize and request each of my former employers to release to Venice Retina all information concerning my former employment and the circumstances of my leaving that employment.

I Agree

Signature*

Use a mouse or your finger

Today's Date*

Comments

This field is for validation purposes and should be left unchanged.

Office Information

Venice Office:
871 Venetia Bay Blvd, Suite 115
Venice, Florida 34285

Phone: 941-202-1900
Fax: (941) 786-3358

Email: [email protected]

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Dr. Anita Shane is an Ophthalmologist serving the citizens of Venice, North Port and Englewood Florida. As a retina specialist, she treats variety of vitreoretinal conditions, including macular degeneration, floaters and flashes, retinal detachments, diabetic eye disease, and more.

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