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Employment

Please complete the form below to apply for employment.

APPLICANT INFORMATION

Position Appiled for
Hours Desired
Full Time
Part Time
PRN
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
Have you ever been convicted of a felony?
Yes
No

EDUCATION

From
To
Did you graduate?
Yes
No
From
To
Did you graduate?
Yes
No
From
To
Did you graduate?
Yes
No

REFERENCES (Please list three professional references)

PREVIOUS EMPLOYMENT

From
To
May we contact your previous supervisor for a reference?
Yes
No
From
To
May we contact your previous supervisor for a reference?
Yes
No

PLEASE LIST ANY SPECIAL SKILL OR CERTIFICATIONS

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview

may result in my release.

This company does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, or on the

basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application is

intended to secure information to be used for such discrimination.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without

cause.

Date

To download the form, click the button below. Once completed, please email it to admin@lauvespediatric.com or deliver it to our office at
2720 Village Ln, Bossier City LA 71112.

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