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
