Application For Employment

Application For Employment
Continuum Therapy Partners is an equal opportunity employer.

Directions: Respond to ALL questions. If a particular question does not apply to you, or the position for which you are applying, write N/A in the blank.

Note: Incomplete applications will not be considered.
Personal Information
Last name
First name
Middle name
Date of application

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Are your employment records kept under another name? If yes, give full name:
Are you legally authorized to work in the United States?
Will you now or in the future require visa sponsorship for employment?
If under 18, do you have a work permit?
How did you hear of job opening?
Position Desired
Specific position applied for
Salary/rate expected
Optional for anyone living in Minnesota
Have you reviewed the job description and confirmed your ability to perform the required duties?
Availability
Are you willing to work weekends
Shift preference
Days available
Professional License and Certification
Type
State
Number
Expiration

MonthDayYear
Date
Additional
Type
State
Number
Expiration

MonthDayYear
Date
Education
Are you current attending school?
Course of study
If yes
High School
High school name
Did you graduate?
High school
Degree
High school
College
College name
Did you graduate?
College
Degree
College
Business or trade school
Business or trade school name
Did you graduate?
Business or trade school
Degree
Business or trade school
Employment History
Have you ever been convicted of a criminal offense (Felony or serious Misdemeanor)?
Please include dismissed or expunged
If yes, state the nature of the crime(s), when and where convicted and disposition of the case.
Are you now, or have you ever been under investigation, suspended or excluded from participation in the Medicare programs or other state and/or federal programs/licenses?
If yes, what’s the reason:
Do you currently or previously have any disciplinary actions on your therapy license?
If yes, what’s the reason:
Instructions
1. List names of present and former employers, beginning with the most recent
2. Explain gaps in employment
3. Record U.S. Military services as a position
May we contact your present employer?
Position 1
Position title
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Employer
City, State
Responsibilities
Reason for leaving
Position 2
Position title
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Employer
City, State
Responsibilities
Reason for leaving
Position 3
Position title
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Employer
City, State
Responsibilities
Reason for leaving
Gaps in employment
Please give reason(s)
I certify that this employment application and any other Continuum Therapy Partners (CTP) documents are not contracts of employment, express or implied, and that if hired, that I may voluntarily leave employment, or may be terminated by the company at any time, for any reason, with or without cause. I understand that any oral or written statements to the contrary are hereby expressly disavowed and will not be relied upon by me.

Please check the following statements:
Electronic signature
Type your full name
Date signed

MonthDayYear
Date
Should be Empty:

Application For Employment

Personal Information

Position Desired

Professional License and Certification

Education

Employment History