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- La Crosse
- Holmen
Our Doctors
Eye Care Services
Eyeglasses & Contacts
Insurance
Blog Posts and News
- Awards and Recognitions
Careers

Hours & Locations
- La Crosse
- Holmen
Our Doctors
Eye Care Services
Eyeglasses & Contacts
Insurance
Blog Posts and News
- Awards and Recognitions
Careers

Hours & Locations
- La Crosse
- Holmen
Our Doctors
Eye Care Services
Eyeglasses & Contacts
Insurance
Blog Posts and News
- Awards and Recognitions
Careers

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Home » Employment Application Form

Employment Application Form

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Date
MM slash DD slash YYYY
Name*
First Middle Last
Present address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone
Email*
Position(s) applying for
Monday: Hours Available:
from
to
Tuesday: Hours Available:
from
to
Wednesday: Hours Available:
from
to
Thursday: Hours Available:
from
to
Friday: Hours Available:
from
to
Saturday: Hours Available:
from
to
If hired, would you have transportation to/from work?
- Yes
- No
If hired, on what date can you start working?
MM slash DD slash YYYY
Salary desired: $
(Please provide a specific amount or range)
Employment desired
- FULL-TIME ONLY
- PART-TIME ONLY
- FULL OR PART-TIME
Location desired
- LA CROSSE ONLY
- HOLMEN ONLY
- LA CROSSE OR HOLMEN
Have you ever applied to or worked for this Company?
- Yes
- No
If yes, please explain (Include date(s)
Do you have any friends, relatives, or acquaintances working for this Company?
- Yes
- No
If yes, state name & relationship
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
- Yes
- No
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description on the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
If yes, please describe the crime – state nature of the crime(s), when and where convicted and disposition of the case
Education
High School
Name of School City/State Number of Years Completed Major/Degree
College or University
Name of School City/State Number of Years Completed Major/Degree
Graduate School
Name of School City/State Number of Years Completed Major/Degree
Work Experience
(Please list your work experience for the past five years beginning with your most recent job held. Attach additional sheets is necessary.)
Are you currently employed?
- Yes
- No
If so, may we contact your current employer?
- Yes
- No
Name of Employer
Supervisor
Telephone Number
Address
Street Address Address Line 2 City State / Province / Region
Length of Employment (Include Dates)
Job Title
Pay/Salary
Duties
Reason for Leaving (be specific)
May we contact this employer for references?
- Yes
- No
Name of employer
Supervisor
Telephone number
Address
Street Address Address Line 2 City State / Province / Region
Length of employment (Include Dates)
Job title
Pay/Salary
Duties
Reason for leaving (be specific)
May we contact this employer for references?
- Yes
- No
Name of employer
Supervisor
Telephone number
Address
Street Address Address Line 2 City State / Province / Region
Length of employment (Include Dates)
Job title
Pay/Salary
Duties
Reason for leaving (be specific)
May we contact this employer for references?
- Yes
- No
We Are an Equal Opportunity Employer
Our Company is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the Company.
References
Please list persons with knowledge of your current work or recent work performance, which you have known at least one year.
Name
First Last
Telephone Number
Email Address
Occupation/Title
Years Acquainted
Name
First Last
Telephone Number
Email Address
Occupation/Title
Years Acquainted
Name
First Last
Telephone Number
Email Address
Occupation/Title
Years Acquainted
Certification*
I certify that I have not knowingly withheld any information that might affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure this employment can be grounds for rejection of my application or, if I am employed by this company, can be terms for my immediate termination from the company.
*
I understand that if I am hired, I will be an employee “at-will” and thus my employment can be terminated at any time either with or without prior notice, and by either me or the company
*
I permit the company to check and verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers & all other persons and entities, from any & all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
*
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Applicant’s Signature*
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Date
MM slash DD slash YYYY

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Patient History Form

Optical Fashions Eye Care Clinic – La Crosse

2104 State Rd 16
La Crosse, WI 54601

Phone: (608) 782-7127
Fax: (608) 782-7124
Email: opticalfashions7127@gmail.com
(Do not send personal health information by email.)

Monday: 7:30 AM - 5:30 PM
Tuesday: 7:30 AM - 5:30 PM
Wednesday: 7:30 AM - 5:30 PM
Thursday: 7:30 AM - 5:30 PM
Friday: 7:30 AM - 2:00 PM
Saturday: Closed
Sunday: Closed

Optical Fashions Eye Care Clinic – Holmen

814 S. Main Street
Holmen, WI 54636

Phone: (608) 782-7127
Fax: (608) 782-7124
Email: opticalfashions7127@gmail.com
(Do not send personal health information by email.)

Monday: 7:30 AM - 5:30 PM
Tuesday: 7:30 AM - 5:30 PM
Wednesday: 7:30 AM - 5:30 PM
Thursday: 7:30 AM - 5:30 PM
Friday: Closed
Saturday: Closed
Sunday: Closed

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Contact Us
What’s New
Disclaimer
Privacy Policy

La Crosse Location

2104 State Rd 16
La Crosse, WI 54601

Phone: (608) 782-7127
Fax: (608) 782-7124
Email: opticalfashions7127@gmail.com
(Do not send personal health information by email.)

Holmen Location

814 S. Main Street
Holmen, WI 54636

Phone: (608) 782-7127
Fax: (608) 782-7124
Email: opticalfashions7127@gmail.com
(Do not send personal health information by email.)

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