Application for Employment

Wee Speech, P.C. 8707 Skokie Blvd. Suite 402 Skokie, IL 60077
Application for Employment
Instructions: Print clearly in black or blue ink. Answer all questions. Sign and date the form.
PERSONAL INFORMATION:
Name

First NameMiddle NameLast Name
Street Address
City, State, Zip Code
Cell phone number
Email
example@example.com
Do you hold the ASHA Clinical Certificate of Competence?

YesNo
Do you have a National Provider ID (NPI)?

YesNo
Do you have a professional license in the state of Illinois?

YesNo
Do you have a Professional Educator License?

YesNo
Are you eligible to work in the United States?

YesNo
Do you have a valid drivers license?

YesNo
Do you own a car?

YesNo
Have you been convicted of or pleaded no contest to a felony within the last five years?

YesNo
Hours Available:
Monday
Tuesday
Wednesday
Friday
Thursday
Sunday
Saturday
What date are you available to start work?

MonthDayYear
Date
EDUCATION:
Name and Address Of School Degree/Diploma Graduation Date

MonthDayYear
Date
EMPLOYMENT HISTORY:
Present or most recent Position:
Employed from/to:
Employer:
Email:
Address:
Phone:
Supervisor
Responsibilities:
Please share your evaluation experience:

AACFeedingOral MotorArticulationApraxiaWord FindingPhonology/LiteracyFluencyVoiceOther
Please share your treatment experience in the following areas:

AACFeedingOral MotorArticulationApraxiaOral MotorWord FindingPhonology/LiteracyVoiceFluencyOther
Please provide a writing sample with identifying information redacted (e.g. evaluation, progress note)

Cancelof
Reason for Leaving current position:
Previous Position:
Employed from/to:
Employer:
Address:
Phone:
Email:
example@example.com
Supervisor:
Reason for Leaving:
May We Contact Your Present Employer?

YesNo
References:
1.
2.
3.
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

I further understand that my employment with Wee Speech, P.C. shall be probationary for a period of 90 days and further that at any time during the probationary period or thereafter, my employment relation with the company is terminable at will for any reason by either party.
Signature

Clear
Date

MonthDayYear
Date
Wee Speech, P.C is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, age or disability.
Should be Empty:

Application for Employment

PERSONAL INFORMATION:

Hours Available:

EDUCATION:

EMPLOYMENT HISTORY:

Previous Position:

References: