Job Application for Dale I. Barr, O. D. and  the Vision Care Clinic

Please complete the following as much as possible. You may also come down to the office and fill out an application at
2730 Union Avenue, San Jose CA 95124 or you can FAX us your resume at 1 408 377 1152.  Please call before you come down to make sure we will have time to help you. Thank you.

Date 

First Name  Middle Intial 

Last Name 

Street Address 

City, State Zip Code + 4 

Phone Number 

Referred by 

Position  Receptionist Bookeeper Optometric Assistant Optician Full time Part time If other, please specify. 

Date you can start 

Expected wages 

Are you employed now? Yes   No

If yes, may we contact your present employer? Yes   No

Name and location of high school, college etc.

School                                           Graduation date

Subjects Studied 

Dates (from/to) 

Name of Employer 

Address of Employer 

Position 

Wages 

Phone Number of Employer 

Contact person 

Their relationship to you 

Name of Employer 

Address of Employer 

Position 

Wages 

Phone Number of Employer 

Contact person 

Their relationship to you 

Name 

Phone number 

Relationship to you 
 

Name 

Phone number 

Relationship to you 
 

Please tell us why you want to work here.

I authorize investigation of all statements contained in this application. Yes    No