Employment Application

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If you are experiencing difficulties completing the online application, please complete the fillable application and return to humanresources@highlandclinic.com or fax to 318-798-4555

Name*
Email Address*
Home address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SSN (Last 4 digits)*
Telephone number*
Cell Phone Number
Are you over 18 years old?
- Yes
- No
Are you authorized to work in the US on an unrestricted basis?
- Yes
- No
Position Applied For:*
Employment Preferred*
Can you work any shift?*
- Yes
- No
Are you willing to work overtime as required?*
- Yes
- No
Date you can start
Are you able to perform the essential functions of the job applied for, with or without a reasonable accomodation?
- Yes
- No
Are you currently employed?
- Yes
- No
May we contact your present employer?
- Yes
- No
Have you ever been terminated from employment or asked to resign by an employer?
- Yes
- No
Details of termination.
Have you ever been convicted of a felony?
- Yes
- No
If yes, describe conditions:
How did you learn of this opening? (Referred By)
Have you worked for this company before?
- Yes
- No
Details of prior work with this company.
Do you know anyone who works for this company?
- Yes
- No
Details of people known at company
Do you have any relatives currently working for this company?
- Yes
- No
Details of relatives working for this company.
High School Attended
High School Location
High School Diploma/Degree
College/University Attended
College/University Location
College/University Year of Graduation
College/University Major
College/University Diploma/Degree
College/University Attended
College/University Location
College/University Year Graduated
College/University Major
College/University Diploma/Degree
Most Recent Employer:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date Started:
MM slash DD slash YYYY
Starting Salary
Starting Position
Date Left
MM slash DD slash YYYY
Salary on Leaving:
Position on Leaving:
Name and Title of Supervisor:
Description of Duties
Reason for leaving?
Employer Before Above:
Phone
Starting Position
Starting Salary
Date Left
MM slash DD slash YYYY
Salary on Leaving:
Position on Leaving:
Name and Title of Supervisor:
Description of Duties:
Reason for Leaving:
Employer Before Above:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date Started:
MM slash DD slash YYYY
Starting salary
Starting Position:
Date Left:
MM slash DD slash YYYY
Salary on Leaving:
Position on Leaving:
Name and Title of Supervisor:
Description of Duties:
Reason for Leaving:
Special skills, experience, or training that applies to the position?
Equipment and / or computer skills?
Certification Name/Type
Certification Issued by
Certification Issue date
MM slash DD slash YYYY
Certification Expiration Date
MM slash DD slash YYYY
Certification Name/Type
Certification Issued by
Certification Expiration Date
MM slash DD slash YYYY
Certification Name/Type
Certification Issued by
Certification Expiration Date
MM slash DD slash YYYY
Reference Name
Reference Email
Reference Phone
Reference Occupation
Reference Years known
Reference name
Reference Email
Reference Phone
Reference Occupation
Reference Years known
Reference name
Reference Email
Reference Phone
Reference Years known
Reference Occupation
Phone
This field is for validation purposes and should be left unchanged.

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1455 East Bert Kouns
Shreveport, LA
Main 318-798-4500
Physician Referral 318-798-4643

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New Online Payment Portal

Highland Clinic is now offering electronic statements and payments!

Highland Clinic is partnering with Health iPASS to send our patients their statements via text message and email. You will be able to pay bills by clicking a secure link in the text message or email, and your Highland Clinic account will be credited immediately. Look for electronic bills coming to your inbox from this email address and/or text messages coming from +1 (318) 300-3130 with secure links to pay.

Make sure we have your cell phone number on file next time you’re in one of our offices, so you can receive your statement via text message for an even faster experience.

Thank You for trusting us with your care!