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Imperial Health
The Science of Health. The art of Caring.
501 Dr. Michael DeBakey Drive
Lake Charles, LA. 70601
Telephone Number: (337) 433-8400
Fax Number: (337) 312-6718
This application will timeout after 15 minutes. Please have all pertinent information (personal, education, past employment, professional licenses/certificates) ready. Sections of this application that are required are noted in red and must be filled out completely.

This information will be used to determine your eligibility for this position. All application material becomes property of Imperial Health.
Only fully completed applications will be considered
If you are having trouble with the on-line application, please fill out an Employment Application (in the menu bar to the left) and email to: jobs@imperialhealth.com

First and last name
Street Address
Mailing Address
City, State, Zip
Home Phone
Cell Phone
Email Address
Have you ever been convicted of a felony or are there any criminal charges pending against you or open arrest warrants?    Yes
If yes, please explain.


High School Name
City, State
High School Diploma    Yes
List of Diploma/Degree


College Name
City, State
Course of Study
List Type of Diploma/Degree
Technical College Name
City, State
Course of Study
List Type of Diploma/Degree


Did you ever serve in the US Armed Forces?    Yes
If so, what branch?


Describe any training you received which is relevant to this position for which you are applying:


Professional licenses/certifications (Include State, Expiration Date and License/Registration Number):
Please check all that apply:
Office/Computer Skills
Ten Key
Multi-Phone Lines
Data Entry
CPT-ICD10 Coding
Electronic Medical Records
Microsoft Office
Outlook Express
Power Point
Please list any other skills:
Position applying for
Department applying for
Date you are available to start working if hired
Salary Desired
Are you applying for
Are you willing to work:
On call
Rotating Shifts
Days available to work
Hours available to work
How did you find out about this position?
If other please list
Have you ever been employed by Imperial Health (The Clinic or Center For Orthopaedics)?    Yes
If yes, what position, department, supervisor, date beginning & ending and reason for leaving
Are you related to anyone presently employed by Imperial Health?    Yes
If yes, please provide the name of the employee and the department in which they work
Are you employed now?    Yes
If so, may we contact your present employer?    Yes
Have you ever been discharged from a job or asked to resign?    Yes
If yes, please explain
Are you authorized to work in the U.S.?    Yes
Can you provide necessary documentation to confirm your authorization to work in the United States? (Immigration Reform and Control Act of 1986)    Yes


Please list name, addrss and phone number of previous employers with most recent employer first. Periods of employment should be included.
Organization Name and Address
Supervisor`s Name and Title:
Phone Number
Job Title:
Starting Salary:
Ending Salary:
Reason for leaving
Organization Name and Address
Supervisor`s Name and Title
Phone Number
Job Title
Starting Salary
Ending Salary
Reason for Leaving
Organization Name
Supervisor`s Name and Title
Phone Number
Job Title
Starting Salary
Ending Salary
Reason for Leaving
May we run an employment check from the employers listed above?    Yes
Has notice been given to your present employer?    Yes

List below the names of three persons not related to you, whom you have worked with or for, who can provide a work-related reference on your behalf.
Work-Related References (Include name, phone number and years acquainted)
As an applicant for employment with Imperial Health, I acknowledge and agree to the terms and conditions listed below.

1. I understand and acknowledge that certain qualifications and competencies for employment are required and that I am required to comply with these requirements.

2. I acknowledge that my initial work assignment and hours do not constitute a binding work agreement or contract between me and Imperial Health and I understand my work hours and the nature of my job duties may change. I acknowledge that I may be asked to work extra hours.

3. I understand that appropriate law enforcement agencies, state and government agencies may be contacted to determine the nature of criminal records or any other background information.

4. I authorize Imperial Health to contact former employers, specifically named by me, for a history of employment and recommendation information. I hereby also agree to hold Imperial Health, its agents and employees and those persons who are contacted in connection with my application, harmless from any legal claim of any nature arising as a result of said party complying with the request concerning the references herein given.

5. I hereby authorize my previous employers, character references, schools, military personnel, and other organizations to release any and all information in relation to this job application to Imperial Health. I hereby agree to hold any person or corporation harmless from any claim of any nature, including court costs or attorney's fees, which could arise as a result of any information of any nature provided either orally or by letter, by my former employers or references as listed in my application.

6. I acknowledge that this is not all-inclusive and that additional requirements and qualifications are contained and enumerated in Imperial Health's Employee Handbook. I understand and agree that these policies and procedures are subject to change and that I am subject to and must abide by the terms and requirements set forth in the employee handbook. I understand that there is no "grandfather clause” that would shield me or other existing employees from new or changed policies duly incorporated into the employee handbook.

7. I understand that I must pass any required pre-employment screenings and skills tests deemed necessary by Imperial Health as a requisite to being employed.

8. I understand that my employment is strictly on an "at will” basis and that it may end at any time. I understand that my employment by Imperial Health may be terminated without cause and such decision to do may be made without regard to satisfactory or unsatisfactory job performance, number of years of employment with Imperial Health or any other factors.

9. I understand and acknowledge that intentional misrepresentation of any information requested of me for purpose of consideration for employment may subject me to possible legal or criminal liability as well as immediate termination should such be discovered after employment.

10. I hereby affirm that the information provided in this application (and/or accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration from employment and may be considered justification for dismissal if discovered at a later date.

I have read and understand the above and agree to all terms and conditions.:    Yes
Title VII of the Civil Rights Act of 1964:
Notice of Non-discrimination

Imperial Health does not discriminate on the basis of race, color, sex, age, religion, national origin, ancestry, disability or against veterans. Imperial Health is an Equal Opportunity Employer.

EEOC Questionnaire
Please take a moment to complete this EEOC questionnaire. The completion of this questionnaire is voluntary and is not a determining criteria for obtaining employment with Imperial Health. This questionnaire will be removed from your application before it is reviewed, and it has no influence on the hiring decision. Thank you in advance for your cooperation.

Date agreed to all terms and conditions (MM/DD/YYYY)

First and Last Name
Sex    Male
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Race    White/Caucasian
   Native Hawaiian
   American Indian
   Two or more races
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