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EMPLOYMENT APPLICATION FORM
At Brinton Vision, we don’t just respect diversity — we thrive on it. We are proud to be an equal opportunity workplace.
Name
First Last
Address
Street Address City State ZIP Code
What position are you applying for?
- Digital Marketing Associate
- Sales Associate
- Ophthalmic Technician
What interests you about working at Brinton Vision?

Employment History
Please include your last 3 jobs beginning with your most recent job held. Attaching a resume will not substitute for completing this section of the application.
Company Name
Start Date
End Date
Description of Duties
Final Wage/Salary*
Final Position/Title
Reason For Leaving
Name of Supervisor
Supervisor's Phone Number
May we contact this employer?
- Yes
- No

Job 2:
Company Name
Start Date
End Date
Description of Duties
Final Wage/Salary
Final Position/Title
Reason For Leaving
Name of Supervisor
Supervisor's Phone Number
May we contact this employer?
- Yes
- No

Job 3:
Company Name
Start Date
End Date
Description of Duties
Final Wage/Salary
Final Position/Title
Reason For Leaving
Name of Supervisor
Supervisor's Phone Number
May we contact this employer?
- Yes
- No

Have you ever quit a job without giving two weeks' notice?
- Yes
- No
If yes, please explain:
Have you ever been involuntarily discharged from a job?
- Yes
- No
If yes, please explain:
Have you ever been convicted or pled guilty to a crime other than a minor traffic violation?
- Yes
- No
If so, please state crime, date, and place where offense occurred
Provide details of the above, including the nature of the offense and successful rehabilitation attempt(s) since the conviction
You are not required to disclose information about physical or mental limitations if you believe they will not interfere with your ability to do this job. However, if you want the employer to consider special arrangements to accommodate a physical or mental impairment, identify that impairment in the text box below and suggest the kind of accommodation that you believe would be appropriate.
I understand that the employer follows an “employment at will” policy, and that I or the employer may terminate my employment at any time, or for any reason consistent with applicable state or federal law; this “employment at will” policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by an Executive of this organization. I understand that this application is not a contract of employment. 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 this application will be active 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 the employer will thoroughly investigate my work and personal history and verify all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named therein, except my current employer if so noted, to provide any information requested about me, and I release them from all liability for damage in providing this information. I understand that my employment may be conditioned on successfully passing a background check. I certify that all the statements herein are true and understand that any falsification or willful omission shall be sufficient cause for dismissal or refusal of employment.
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Job Application

Step 1 of 7

EMPLOYMENT APPLICATION FORM

Education

Employment History

Job 2:

Job 3:

Step 1 of 7

EMPLOYMENT APPLICATION FORM

Education

Employment History

Job 2:

Job 3: