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Please Fill Out and Email To:
msliz4kidz@gmail.com or msliz4kidz@yahoo.com
or Upload to Care Tec Pediatric Center,LLC/Louisiana Care Partners Website
Louisiana Care Partners,LLC
3600 Jackson Street, Suite 114D, Alexandria, La, 71303
318-451-3989 CENTER 337-573-4307 FAX
337-351-1841 ADMINISTRATION
Care Tec Pediatric Center, LLC
2840 Military Highway, Suite C, Pineville, La, 71360
337-856-6946 CENTER 337-573-4307 FAX
337-301-1029 ADMINISTRATION
EMPLOYMENT APPLICATION
POSITION APPLIED FOR:________________________________________________ DATE OF APPLICATION:_________________ INTERVIEW AVAILABILITY DATE:_________________
APPLICANT HOME PHONE:____________________________________________ CELL or ALTERNATE PHONE:_________________________ E-MAIL: _____________________________
NAME:___________________________________________________________________________________________________________________________________________
LAST FIRST MIDDLE
ADDRESS:
____________________________________________________________________________ ARE YOU LEGALLY ELIGIBLE FOR US EMPLOYMENT?
____________________________________________________________________________ YES NO (IF YES VERIFICATION REQUIRED)
____________________________________________________________________________ I AM ABLE TO WORK REMOTELY VIA TELEHEALTH: YES NO
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS IF NECESSARY, FOR THE JOB I AM ABLE TO:
MEET THE ADA REQUIREMENTS OF THE POSITION I AM APPLYING FOR , WITH OR WITHOUT ACCOMMODATION
PLEASE SPECIFY : WORK OVERTIME?
PROVIDE A VALID LOUISIANA OR TEXAS DRIVER’S LICENSE? YES NO
IF NECESSARY FOR THE JOB, ARE YOU OVER (PLEASE MARK ONE) 16__ 18__ 19__ 21__
I WILL BE ABLE TO REPORT TO WORK ________ DAYS AFTER BEING NOTIFIED THAT I AM HIRED.
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EDUCATION:
HIGH SCHOOL
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YES COMPLETED
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FIELD OF STUDY
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GRADUATE OR DEGREE
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COLLEGE/UNIVERSITY
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BUSINESS/TECHNICAL
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OTHER (MAY INCLUDE GRAMMAR SCHOOL)
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MILITARY SERVICE: YES NO
DUTY/SPECIALIZED TRAINING:________________________________________________________________________-_______
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REFERENCES: LIST TWO PERSONAL REFERENCES WHO ARE NOT RELATIVES OR FORMER SUPERVISORS.
_________________________________________________________________________________________________________
NAME ADDRESS TELEPHONE OCCUPATION YEARS KNOWN
_________________________________________________________________________________________________________
NAME ADDRESS TELEPHONE OCCUPATION YEARS KNOWN
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EMPLOYMENT: LIST LAST EMPLOYMENT FIRST. INCLUDE SUMMER OR TEMPORARY JOBS. BE SURE ALL YOUR EXPERIENCE OR EMPLOYERS RELATED TO
THIS JOB ARE LISTED HERE, IN THE SUMMARY (FOLLOWING THIS SECTION) OR USE AN EXTRA SHEET OF PAPER IF NECESSARY.
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EMPLOYER NAME AND ADDRESS:
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POSITION TITLE/DUTIES SKILLS
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DATES EMPLOYED
 FROM TO
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REASON FOR LEAVING
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SUPERVISOR’S NAME: TELEPHONE
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EMPLOYER NAME AND ADDRESS:
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POSITION TITLE/DUTIES SKILLS
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DATES EMPLOYED
FROM TO
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REASON FOR LEAVING
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SUPERVISOR’S NAME: TELEPHONE
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EMPLOYER NAME AND ADDRESS:
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POSITION TITLE/DUTIES SKILLS
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DATES EMPLOYED
FROM TO
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REASON FOR LEAVING
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SUPERVISOR’S NAME: TELEPHONE
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EMPLOYER NAME AND ADDRESS:
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POSITION TITLE/DUTIES SKILLS
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DATES EMPLOYED
FROM TO
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REASON FOR LEAVING
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SUPERVISOR’S NAME: TELEPHONE
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SUMMARIZE OTHER EMPLOYMENT RELATED TO THIS JOB__________________________________________________
TYPES OF COMPUTERS, OTHER ELECTRONIC, OR MECHANICAL EQUIPMENT THAT YOU ARE QUALIFIED TO OPERATE OR REPAIR:_______________________________________________________________________________________________________________________
PROFESSIONAL LICENSES, CERTIFICATIONS OR REGISTRATIONS: __________________________________________________________
ADDITIONAL SKILLS INCLUDING SUPERVISION SKILLS, OTHER LANGUAGES, OR INFORMATION REGARDING THE CAREER/OCCUPATION YOU WISH TO BRING TO THE EMPLOYER’S ATTENTION_____________________________________________________________________________________________________
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