← Back to Careers & Jobs Application for Employment Complete the form below to apply. Once you submit it, your completed application will be emailed directly to our HR team as a PDF. Personal InformationFull Name* First Name Last NameEmail Address* Phone Number* Home Address* Street Address City State / Province Zip / Postal Code Select CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountry Date of Application* Position & AvailabilityPosition Applying For* Date Available to Start* Employment Type Desired* Full-Time Part-Time Temporary SeasonalAre you at least 18 years of age?* Yes NoAre you legally authorized to work in the United States?* Yes NoHave you previously applied to or worked for this practice? Yes NoIf you previously applied/worked here, please give approximate date(s) and position(s)Have you ever been convicted of a crime? (A conviction will not necessarily disqualify you from employment.) Yes NoIf yes, please explainHow did you hear about this position?EducationHigh School Name & LocationHigh School Years Attended / Diploma or GEDCollege/University Name & LocationDegree Earned & Major/Field of StudyOther Certifications or Vocational/Technical TrainingEmployment History — Most Recent EmployerEmployer NameEmployer Address Employer Phone Supervisor NameJob TitleReason for Leaving Employed From Employed To May we contact this employer? Yes NoEmployment History — Previous EmployerEmployer Name (2)Employer Address (2) Employer Phone (2) Supervisor Name (2)Job Title (2)Reason for Leaving (2) Employed From (2) Employed To (2) May we contact this employer? (2) Yes NoSkills & QualificationsRelevant skills, certifications, and licenses (e.g. COA/COT/COMT, EMR systems, ICD-10 coding)Languages SpokenProfessional References (please list three, not relatives)Reference 1: Name, Relationship, Company, Phone, EmailReference 2: Name, Relationship, Company, Phone, EmailReference 3: Name, Relationship, Company, Phone, EmailCertificationI certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading statements may be grounds for refusal of employment or termination if discovered later. I authorize Fox Valley Ophthalmology, Ltd. to verify this information and contact my references and previous employers.* I certify and agree to the aboveApplicant Signature (type full legal name)* Date* Upload Resume/CV (optional) Choose File No file chosen Submit Application
