Lakeland Surgical & Diagnostic Center
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Employment Application

  • Personal Information

  • Please enter a number less than or equal to 17.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
    Note: The Federal Immigration and Reform and Control Act of 1986 requires that an INS Employment Eligibility Verification Form I-9 be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization for work. This federal requirement must be satisfied as a condition of employment.
    Note: Answering "yes" does not automatically exclude you from consideration for the position. If yes, please explain on the Additional comments section, including the penalty imposed.
  • MM slash DD slash YYYY
    If yes, please explain on the Additional Comments Section. Note: Answering "yes" does not automatically exclude you from futher consideration for this position.
    If yes, include nature of the intentional tort and the disposition of the action in the Additional Comments Section. Note: Answering "yes" does not automatically exclude you from further consideration for this position.
  • Driving Record

  • Additional Comments

  • Education, Training, And Professional Licensure, Registry and Certification

  • High School Name & LocationCourse of StudyYears CompletedDid you Graduate?Type of Diploma or Degree
  • College/University Name & LocationCourse of StudyYears CompletedDid you Graduate?Type of Diploma or Degree
  • College/University Name & LocationCourse of StudyYears CompletedDid you Graduate?Type of Diploma or Degree
  • Graduate/Professional School Name & LocationCourse of StudyYears CompletedDid you Graduate?Type of Diploma or Degree
  • Training in Specialty AreasCourse of StudyYears CompletedDid you Graduate?Type of Diploma or Degree
  • State/JurisdictionLicense No.Type of Licensure 
  • MM slash DD slash YYYY
  • Employment History

    Starting with current or most recent, list all employers past and present. Include self-employment and summer and part-time jobs. If more space is required, please continue on a separate sheet. You may attach a resume, but you must complete this section of this Application as well. Lakeland Surgical & Diagnostic Center, L.L.P. verifies all information disclosed in this section.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

    You may be required to furnish a copy of the agreement.
  • References

  • NameRelationship to youOccupation and TitlePhone No.Years Known 
  • Military

  • MM slash DD slash YYYY
  • Resume

  • Applicant’s Acknowledgement

    I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document will disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document will cause for my dismissal at any time without prior notice.

    I understand that, if employed, my employment is not for a specific term and may be terminated by me or my Employer with or without notice or cause at any time. I further understand that no oral promise, Employer(s) policy, custom, business practice (including the Employee Handbook or any personal materials) constitute an employment contract or modification of at will employment relationship between me and the Employer.

    I understand that applicants for certain positions may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job related tests; take a driver’s examination; submit to a background investigation; take a pre-employment drug and nicotine test. If I am offered employment or start work before any of the required tests are completed, my employment is contingent on a satisfactory result on all required tests. I authorize Lakeland Surgical & Diagnostic Center, L.L.P. and its clients to release the results of the background checks (if any) and my pre-employment drug/alcohol and nicotine test (if any), any information on this application and any relevant information about me to each other and release Lakeland Surgical & Diagnostic Center, L.L.P. and its clients from any and all claims related to the lawful release of this information. I further authorize the release of any background check results of any drug/alcohol and nicotine test to any state or federal authority requesting such information and in response to valid subpoena or other legal document.

    In compliance with the federal Immigration Reform & Control Act, I agree, if hired, to provide within three (3) business days from the date that my employment begins, proof of my identity and eligibility for employment in the United States.

    Further, I understand that, if I am employed, all materials, equipment and space allocated to me for the discharge of my duties may be inspected as deemed necessary by Lakeland Surgical & Diagnostic Center, L.L.P. at its sole discretion.

  • This field is for validation purposes and should be left unchanged.
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Post-Procedure
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Florida Campus

863-683-2268
1315 North Florida Avenue | Lakeland, FL 33805
Monday-Friday | 6:30am-7pm
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Griffin Campus

863-687-0566
818 Griffin Road | Lakeland, FL 33805
Monday-Friday | 6:30am-7pm
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Corporate Campus

863-683-2428
115 South Missouri Avenue | Lakeland, FL 33815
Monday-Friday | 8am-4:30pm
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