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Employee Application

Fields marked with an * are required

LA PEER Surgery Center Employment Application Form

Personal Information

Do you possess a valid driver's license?

Work Experience - List Most Recent Job First

Date, Month and Year

Name, Address, Phone Number of Employer

Describe the Work You Did


Reason for Leaving

General Information



Course of Study

Years Attended




How do you know?

How long have you known?

Phone Number


I certify that the information provided herein is true and correct to the best of my knowledge. I understand that, if employed, falsified statements on this Application for Employment form will be considered grounds for termination. I authorize the company to thoroughly investigate my work experience and any other matters related to my suitability for employment. I further authorize my former employers to disclose to the company any and all information that may be needed concerning my previous employment within the guidelines of the law. In addition, I hereby release the company, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of, or in any way related to, such disclosure. I acknowledge that, if employed, both the company and I have the right to terminate the employment relationship at any time, with or without cause or advance notice. This employment at will relationship will remain in effect throughout my employment with the company and may not be modified by any oral or implied agreement.