APPLICATION FOR EMPLOYMENT			Children's Clinic of SWLA 2903 1st Avenue Lake Charles, LA 70601
Personal Information
Name:				Date:
Social Security Number:		Email address:
Home address:
Home phone:		Cell phone:
Position Applying For
Title:	Salary desired:				Full time or Part time:
Referred by:					Date available:
Employment History and Skills
Are you currently employed?	Where?
Are you acquainted with or related to any person employed here?
If so, please list name:
Date available for work:

Will you be able to work: Overtime ____ Weekends ____ Holidays ____
Can you: Type Yes ______ No ______ Speed ________ Take dictation Yes ______ No ______ Speed ________ Operate dictation equipment Yes ______ No ______ Run 10-Key adding machine Yes ______ No ______ Do you know medical terminology Yes ______ No ______
List other secretarial, clerical or accounting skills
Education
High school (Name,City,State):
Graduation date:
Business, technical school, or college:
Dates attended:
Degree and major:
Professional References
Please list three with contact information.