Job Application

Position Applying For:

Name: Last, First, Middle Cell Phone Email Address

Social Security Number: - -

Address: Street City State Zip code

Work Experience/ Position Company From To

Educational History

High School Completed: Yes or No Graduation Year

Higher Education Completed: Yes or No Graduation Year

Are you at least 18 years of age? Yes No

600 Cypress Street 2800 Country Club Road 340 N Hwy 171 Suite B
Sulphur, LA 70663 Lake Charles, LA 70605 Lake Charles, LA 70611
(337)527-6371 (337)477-0935 (337)419-0040

I state the information contained in the foregoing statements is complete, true, and correct. I understand
that if I am employed, any misrepresentation or omission of material facts on this application is sufficient cause for
dismissal. I agree that, if hired, I will conform to the rules and regulations of The Pediatric Center and further agree
that my employment is for no definite period of time and can be terminated, with or without cause, and with or
without notice, at any time at the option of either The Pediatric Center or myself. No employee of the Pediatric
Center other than the Owner has any authority to enter into any agreement for employment for any specified period
of time or to make any agreement contrary to the foregoing, and no such agreement has been made. The Pediatric
Center, in considering my application for employment, may verify the information set forth on this application and
obtain additional information relating to my background. I authorize all persons, schools, companies, corporations,
credit bureaus, consumer reporting agencies, and law enforcement agencies to supply any information concerning
my background. It is understood that I may be asked to take a polygraph examination in cases involving sabotage,
theft, or other incidents resulting in economic loss to The Pediatric Center. The use of such examinations will be in
conformance with applicable laws.

I further promise and agree to observe all The Pediatric Center rules and regulations, to faithfully perform
all duties that may be assigned to me, and to promptly inform my employer of and act or conduct of other people,
which come to my attention, and which is considered detrimental to the best interest of The Pediatric Center.

Applicant Signature Date

For Office Use Only

Date Employed Job Title Starting Rate

600 Cypress Street 2800 Country Club Road 340 N Hwy 171 Suite B
Sulphur, LA 70663 Lake Charles, LA 70605 Lake Charles, LA 70611
(337)527-6371 (337)477-0935 (337)419-0040

Disclosure Statement

I acknowledge the filing of my application with The Pediatric Center of SWLA (TPC) is to
obtain employment and the information given herein is factual. I hereby authorize you to
make inquiries of my previous employers, educational institutions, friends, neighbors,
associates and references about these matters. Inquires will be conducted through
personal interviews and/or criminal background checks. I further understand that I have
the right to make a request in writing to TPC to learn the complete nature and scope of this
investigative report as described above.

I hereby affirm that the information I provided in my application is true and complete. I
understand that providing false or incomplete information to TPC could result in a dismissal
from or refusal of employment.

Name

Signature

Date

600 Cypress Street 2800 Country Club Road 340 N Hwy 171 Suite B
Sulphur, LA 70663 Lake Charles, LA 70605 Lake Charles, LA 70611
(337)527-6371 (337)477-0935 (337)419-0040