Employment Application

Employment Application
Full Legal Name*

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Place of Birth (City, State, Country)*
Date of Birth*

MonthDayYear
Date
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Check one *

I am seeking full-time work.I am seeking part-time work.I am seeking temporary work.
Date available to start work*

MonthDayYear
Date
I can speak english: *

FluentlyPoorlyNot at all
I am a U.S. Citizen or am authorized to work in th U.S. on an unrestricted basis:*

YesNo
Have you ever been convicted of a felony?*

YesNo
If you have been convicted of a crime, please explain.
Have you ever been convicted, involved, or currently in a pending resolution of ANY criminal offence related to HEALTH CARE?*

YesNo
Do you have a current driver's license?*

YesNo
Do you have reliable transportation?*

YesNo

State all the hours you are available to work in the chart below.

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
From:
To:

Education History
High School
High School Name*
High School City, State*
Graduated *

YesNo
College

(If none, type "n/a")
College Name*
Years Attended
Focus of Study
Graduated

YesNo
Other Education
Other education:
Employment History
Most Recent Employer

(if none, type n/a)
Most Recent Employer Name*
Type the dates you worked for your most recent employer. If you are still employed with this employer, type "current" in the date ended box.*

Date Started Date Ended

Dates worked for
Most Recent Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary
Type of work perfomed
Reason for Leaving
Supervisors Name and Position
Second Most Recent Employer
Second Most Recent Employer Name
Date Started Date Ended

Dates worked for
Second Most Recent Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary
Type of work perfomed
Reason for Leaving
Supervisors Name and Position
List three references (non-family members) Please include their full name, phone number, occupation, and relationship to you. *
Are you willing to allow GSO to conduct a background check?Selecting "yes" gives GSO and/or its agents to contact your references, and otherwise conduct an investigation into your background, including, without limitation, information related to your character, job performance and work habits, motor vehicle and criminal records, verification of education and licenses/certifications, employment verification and verification of submitted application form. Selecting "yes" releases GSO and its agents and those contacted by GSO and/or its agents from any liability associated with such investigation. Selecting "yes" also means that you understand that you may be refused employment on the basis of information received as the result of any investigation into your background.*

yesno
Are you willing to abide by GSO's professional dress code?The employee agrees to follow GSO's dress or uniform code. Everyone is expected to be well-groomed and wear clean clothing free of holes, tears, or other signs of wear. Employee must maintain neat clean hair and neat facial hair (when applicable). For the safety of patients, no strong perfumes, body sprays, or colognes are permitted. Clothing with offensive or inappropriate designs or stamps is not allowed. Clothing should be modest and not revealing. Short skirts, short dresses, tank tops, low-cut shirts, braless appearance, exposed cleavage, sleeveless shirts, halter tops, spaghetti straps, crop tops, and low-cut pants are not permitted. Tattoos should be covered to the best of the employee's ability. Body piercings must be limited to earrings and/or a nose stud. Nose rings are not permitted. Socks and closed-toe shoes must be worn. Open-toe shoes are not permitted.*

yesno
Position(s) you are applying for? Select any you are interested in. It is okay to select more than one area of interest.*

Front Desk/ReceptionistSchedulerBillingPatient CoordinatorOphthalmic TechnicianOphthalmic Office Assistant
Skills/Experience (Check any that apply to you)*

Ophthalmology ExperienceMedical/Patient SchedulingSurgery SchedulingMedical RecordsBillingEMR systemsHIPAAInsurance VerificationMedical Office ExperiencePatient Care/Patient HistoryVital SignsRefraction ( Phoropter and/or Loose Lens)Lenosmetry StereoTopographyPupil MeasuringStereo TestingHumphrey Visual Field PerimetryGoldmann PerimetryOCTBiometry (IOL Master)Google WorkspaceComputer SkillsSocial MediaJotFormWix/Wesbite developmentOther
Valuable Personal Skills (Check any that apply to you)*

Planning and organizationCritical thinkingProblem-solving skillsTeamworkLeadership skillsTime management/timelyResults-oriented mindsetAnalytical thinkingEffective communicationReliable, dependable, loyalCan work well under pressureMaintains professionalism at all times
Certifications (Check any that apply to you)*

Certified Ophthalmic Assistant (COA)Certified Ophthalmic Technician (COT)Certified Ophthalmic Medical Technician (COMT)Certified Surgical Technologists (CST)Certified Professional Biller (CPB)Certified Billing and Coding Specialist (CBCS)Certified Medical Administrative Assistant (CMAA)Certified Medical Office Manager (CMOM)Certified Medical Insurance Specialist (CMIS)None of the aboveOther
Can you perform the essential job with or without reasonable accommodation?*

yesno
Do you understand that due to the nature of the services we provide, an exceptional record of attendance, promptness, and dependability is required of all GSO employees?*

yesno
Do you understand that employment is contingent upon satisfactory experience and/or education, prior employment and reference verifications?*

yesno
I understand that this employment application or the granting of an oral interview does not constitute a contract of employment or a promise of future benefits by GSO.*

yesno
I also understand and agree that if hired, my employment will be for no specific duration, will be at-will in nature, and may be terminated, with or without cause, at any time by either myself or my employer.*

yesno
In the event of my employment with GSO, I agree to abide by all established rules and procedures and GSO's Employee Handbook. I also understand that that such rules and procedures will be changed and updated on a regular basis.*

yesno
Do you understand that the first few months of employment at GSO will be considered an initial employment period and/or adaptation and that employment may be terminated during this period by either the employee and/or the employer without prejudice and with no eligibility for accrued or severance pay?*

yesno
I agree that in the event of a working injury, GSO has my consent for treatment.*

yesno
In the event that I am photographed during the course of my employment, GSO has my permission to use any and all photos for various purposes.*

yesno
I agree to release and hold harmless GSO and/or its agents and any person or organization providing information to them from any claims I may have, now or in the future, relating in any manner to giving or receiving this information, including without limitation, claims for slander, defamation and wrongful termination.*

yesno
Feel free to upload your resume if you have one.

Upload a File

Cancelof
GSO is an Equal Opportunity Employer. Our policy is clear: there shall be no discrimination on the basis of age, disability, sex, race, religion or belief, gender, marriage/civil partnership, pregnancy/maternity, or sexual orientation.

We are an inclusive organization and actively promote equality of opportunity for all with the right mix of talent, skills and potential. We welcome all applications from a wide range of candidates. Selection for roles will be based on individual merit alone.
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Employment Application

Education History

High School

College

Other Education

Employment History

Most Recent Employer

Second Most Recent Employer