Application for Employment

An Equal Opportunity Employer

All applicants are considered without regard to race, color, gender, religion, national origin, age, marital or veteran status, mental or physical disability unrelated to job performance or any other legally protected status.

Please Confirm Email *

Position Applying For *

Physical Therapist
Occupational Therapist
Speech-Language Pathologist
Physical Therapy Assistant
Occupational Therapy Assistant
Speech Therapy Assistant
Administrative Clinical Care Coordinator
No elements found. Consider changing the search query.
List is empty.

Personal Information

First Name *

Last Name *

Phone *

Address

Street Address *

City

State

Country

Country

Postal code

Legal Information

Are you legally eligible for employment in the United States?

Yes

No

United States Visa status, if applicable:

Have you been convicted of a felony?

Yes

No

If yes, please explain circumstances

Social Security #

Optional

Driver's License #

Are you at least 18 years old?

Yes

No

Emergency Contact Name

Emergency Contact Phone Number

Position Information

Salary/Hrly Rate Desired

$

Employment Status Desired

Full Time

Part Time

What hours are you available to work?

If hired, when could you start?

Why are you currently seeking new employment?

Rank Your Priorities (1=highest, 6=lowest) from the following:

Work Life Integration
Highest Compensation
Career Growth Potential
Benefits (PTO, Medical, etc.)
Employee Environment + Culture
Steady Paycheck

What does your ideal job look like (Functions and Responsibility)?

If you could teach a class tomorrow, what would the topic and learning objective be?

Employment History

(Most Recent First)

Previous Employer 1

Job Title
Employer
Start Date
End Date
Starting Salary
Ending Salary
Supervisor Name
May We Contact
Supervisor Phone
Reason for Leaving

Employment History

If not applicable, please click "Next"

Previous Employer 2

Job Title
Employer
Start Date
End Date
Starting Salary
Ending Salary
Supervisor Name
May We Contact
Supervisor Phone
Reason for Leaving

Employment History

If not applicable, please click "Next"

Previous Employer 3

Job Title
Employer
Start Date
End Date
Starting Salary
Ending Salary
Supervisor Name
May We Contact
Supervisor Phone
Reason for Leaving

Education

If not applicable, please click "Next"

High School

Name
Location
Dates Attended
Did you graduate?
Graduation Year

Education

If not applicable, please click "Next"

College/University

Name
Location
Dates Attended
Degree Received
Subjects Studied
Did You Graduate

Education

If not applicable, please click "Next"

Graduate School

Name
Location
Dates Attended
Degree Received
Subjects Studied
Did you graduate?

Education

If not applicable, please click "Next"

Tech School (if applicable)

Name
Location
Dates Attended
Subjects Studied
Did You Graduate?

Education

If not applicable, please click "Next"

Other Schooling (if applicable)

Name
Location
Dates Attended
Degree Received
Subjects Studied
Did you graduate?

Education

If not applicable, please click "Next"

Special courses, training, or experience acquired, including military experience:

Skills

Clerical/Office Skills

Computer Skills

Name of Software

Operating System

PC

Mac

WPM

Languages

CERTIFICATION & AUTHORIZATION

I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand that any misrepresentations or omissions of facts in this application are grounds for disqualification from further consideration or for dismissal from employment.

I authorize the company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position.

If employed, I agree to conform to the rules, regulations and policies of the company. I understand that I will be an employee “at will” and either the company or I may terminate my employment relationship at any time for any reason not in violation of law.

I hereby acknowledge that I have read and fully understand the forgoing and seek employment under these conditions.

Signature of Applicant

NEXT