Therapist Job Application

Therapist Job Application

Thank you for taking the time to submit a job application. We are very excited to learn more about you and are looking forward to meeting with you soon! All applicants are subject to a background search. Applicants may be tested for illegal drugs.
Today's Date *

Month Day Year
Date
What position are you applying for? *

Physical Therapist Occupational Therapist Speech Language Pathologist Speech Language Pathologist - CF
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How long have you lived at the above address? *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Date of Birth *

Month Day Year
Date
What is your desired salary / hourly rate? *

What are the days and hours you are available to work?

COVID-19 Vaccination Status

Federal mandate required all healthcare workers and support staff working in facilities that participate in Medicare of Medicaid programs to be fully vaccinated against COVID-19. Employees may request religious and medical exemptions.
*

Fully vaccinated (2 doses of Pfizer or Moderna, or 1 dose of Johnson & Johnson) Partially vaccinated or planning to get vaccinated Interested in applying for exemption secondary to medical or religious reasons
What is your highest level of education completed? *

High School College Graduate School Other
Name and Location of School, Years Completed, and the Major/Degree? *
Have you ever been convicted of a crime? *

Yes No
If yes to the above question, please list the number(s) of convictions, nature of offense(s), and date(s): *
Please list any other relevant information that may be found in a background check: *
Do you have a driver's license? *

Yes No
Driver's License State & Number (if applicable)
Please list two references other than close friends or relatives. For each reference, please include their name, position, company, address, and phone number. *
Are you now a member of the National Guard or Reserves? *

Yes No
If yes to the above question, what is your discharge date? *
Work Experience
Work Experience 1 *
Work Experience 2
Work Experience 3
May we contact your present employer? *

Yes No
Please choose one characteristic which you identify more with: *

Introverted Extroverted
Please choose one characteristic which you identify more with: *

Task-Oriented People Oriented
Please choose one characteristic which you identify more with: *

Laid Back Assertive
Please choose one characteristic which you identify more with: *

Playful Serious
In terms of my career, in one (1) year, I would like to see myself: *
Use the space below to summarize any additional information that you would like to share with us:
Please Upload Your Resume *

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Therapist Job Application

COVID-19 Vaccination Status

Work Experience