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Please fill out the application in its entirety.

Step 1 of 9 - Applicant Information

11%

Applicant Information
Please provide us with your personal information including the date you are available to start. All forms are required.
Full Name:*

Last
First

First
M.I.

M.I.
Date:
MM slash DD slash YYYY
Address:*

Street Address
Apt./Unit#

Apt./Unit#
City*

City
State*
State
ZIP Code*

ZIP Code
Phone:*
Email:*
Date Available to Start:*
MM slash DD slash YYYY
Social Security No.:*
Desired Salary:*
Position Applying for:*
Are you a citizen of the United States?*
- Yes
- No
If no, are you authorized to work in the U.S.?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If yes, when?*
Have you ever been convicted of a felony?*
- Yes
- No
If yes, explain:*

Education
Please provide us with your education background. If not applicable, enter "N/A".
High School:*
From:*
MM slash DD slash YYYY
To:*
MM slash DD slash YYYY
Did you graduate?*
- Yes
- No
Diploma:*
College:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree:
Other:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree:
- Add other
Other:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree:

References
Please provide us with three professional references. All forms are required.
Full Name:*
Relationship:*
Company:*
Phone:*
Address:
Full Name:*
Relationship:*
Company:*
Phone:*
Address:
Full Name:*
Relationship:*
Company:*
Phone:*
Address:

Military Service
Please provide us with your military service background. If not applicable, enter "N/A".
Branch:
From:
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:

Upload Resume*
Accepted file types: doc, docx, pdf, Max. file size: 5 MB.

Disclaimer and signature
Please provide your signature if you certify that your answers are true and complete to the best of your knowledge.
NOTICE ABOUT INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled upon your request to be informed about the information Clear Lake Specialties (CLS) collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to have CLS correct information about you that is held by us (CLS) and is incorrect. The information that CLS collects will be retained and maintained as required by Texas Records Retention Laws (Section 441.180 et seq. of the Texas Government Code) and Rules.

Falsification of any information on this form will void your Application for Employment and any actions based on it. The information on the Application for Employment, together with any attachments, is the property of Clear Lake Specialties.
Name:*
First Middle Last
SSN**

SSN*
List any former names used:
Driver License Number and Issuing State:*
Date of Birth:*
MM slash DD slash YYYY
Maiden Name:
Current and Previous Addresses:*
Race:
Gender:
Height
Weight:
I hereby authorize any law enforcement agency to furnish Clear Lake Specialties or its agent information related to my criminal history. I hereby release Clear Lake Specialties, all its agents and employees, the law enforcement agency and all employees of law enforcement agencies furnishing information, from all liability resulting from the furnishing of this information to Clear Lake Specialties. In addition, I authorize Clear Lake Specialties or its agent to verify information related to education. I certify that statements made by me on this form are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that any false statements made herein will void my Application for Employment and any actions based on it.
Signature:*
Date:*
MM slash DD slash YYYY

Background Check
FALSIFICATION OF ANY INFORMATION ON THIS FORM WILL VOID YOUR APPLICATION FOR EMPLOYMENT AND ANY ACTIONS BASED ON IT. THE INFORMATION ON THE APPLICATION FOR EMPLOYMENT, TOGETHER WITH ANY ATTACHMENTS, IS THE PROPERTY OF CLEAR LAKE SPECIALTIES.
I certify that my statements are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature:*
Date:*
MM slash DD slash YYYY

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Rheumatology
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