An Outpatient Surgery
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Employee Application

Fields marked with an * are required

LA PEER Surgery Center Employment Application Form

Personal Information

Have you ever been convicted of a felony?

Do you possess a valid driver's license?

Are you available to work overtime?

Employment Desired

Are you currently employed?

If so, may we inquire your present employer?

Have you ever applied to this company before?


Name and Location of School

Years Attended

Did you Graduate?

Subjects Studied or Degree attained

Former Employers (list below last 3 employers, starting with last one first)

Date, Month and Year

Name, Address, Phone Number of Employer



Reason for Leaving



How do you know?

How long have you known?

Phone Number


I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements container herein and the education institutions, references and employers listed above to give you any and all information concerning my education, previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization  of such information.

I understand and agree that any offer for employment will not be for any specified period of time, unless it is in writing and signed by an authorized company representative.