Application Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Email Address*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Please list previous address if address has changed during the past 5 years.DayTimePhone*￼ Evening Phone*Emergency Contact name First Last Emergency Contact Phone*Are you over 17 years of age and under 70?*YesNoPosition Desired*Salary Expected*Would you consider a position that pays less?*YesNoDate Available*Immediately1 week notice2 week noticePreviously applied for employment with Access Optics or one of its affiliate companies*YesNoIf Yes, Where and When?Have you previously been employed by Access Optics or one of its affiliate companies?*YesNoIf Yes, Where and When?Name of SupervisorHave you been convicted of a crime (including Military Convictions)*YesNoAre you involved in any court actions?*YesNoIf Yes, Please explainEducationHighest Degree*GEDHigh SchoolSome CollegeAssociatesBachelorsMastersPhDCompany Name*Company Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ￼ May we contact?*YesNoJob Description*Reason for Leaving*ReferencesReference #1 Name* First Last Reference #1 Employer*Reference #1 City, St & Zip*Reference #1 Phone*Reference #1 Years Known*Please enter a value between 0 and 99.If, Yes, Relative’s Name Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Relationship Place of Work Complete this section for office positions only.Skills Word Processing Spread Sheets Windows 10 Key By Touch 10 Key By Sight Calculator By Touch Calculator By Sight Other: RankDates From To Primary OccupationAdditional InfoPlease provide any additional information that may aid in the consideration of your Application (Foreign Language, Community or Trade Organization involvement, etc.)I certify that the information given above is complete and correct to the best of my knowledge and I understand that any misrepresentation or omission of material facts, are grounds for immediate dismissal. I authorize the companies, schools, persons and others named as references to furnish Access Optics and its affiliate companies with any information they may have regarding me and agree they shall be not liable in any respect should my employment be terminated because of misrepresentation or omission of material facts in this application. I agree to a medical examination and/or drug screening analysis when job offer is extended, if requested. In consideration of my employment by Access Optics or one of its affiliate companies, I agree to conform to the rules and regulations of Access Optics and I understand and agree that my employment and compensation with Access Optics or one of its affiliate companies may be terminated with or without cause and with or without notice at any time at the option of myself or the company.DISCLOSURE TO and AUTHORIZATON BY EMPLOYMENT APPLICANT REGARDING PROCUREMENT OF BACKGROUND CHECK, CONSUMER REPORT, DRUG SCREEN TESTING In connection with your application for employment, we may procure or cause to be procured a background check, consumer report, and drug screening on you as a part of the process for considering your candidacy as an employee. In the event that information from the report is utilized in whole or in part in making an adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the law. By your signature below, you hereby authorize us to obtain a background check, consumer report about you, and authorizes us to obtain drug screening in order to consider you for employment, and it is your agreement that you waive and release all claims you may have against the Company which arise out of the Company’s obtaining a background check, consumer report or drug screening test.