Therapist Application
Provide complete and accurate information in all sections.
Which of the following best describes your role?
*
PT
PTA
OT
OTA
ST
STA
Applicant Name:
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First Name
Middle Initial
Last Name
Title/Position:
*
Application Date:
*
-
Month
-
Day
Year
Date
Address
*
Street Address
City
State / Province
Postal / Zip Code
Phone:
Cel:
*
Email:
*
SS #:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
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Licences & Certificates
Professional License #:
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Professional License Expiration Date:
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Month
-
Day
Year
Date
State Issued:
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Driver Lic. #:
*
Driver Lic. Expiration Date:
*
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Month
-
Day
Year
Date
Professional Liability Information:
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Date you can start:
*
-
Month
-
Day
Year
Date
Are you currently employed:
*
yes
no
If employed, may we inquire of your current employer:
yes
no
Have you applied to this agency before?:
*
yes
no
If so, when:
EDUCATION
Please complete as much as possible!
HIGH SCHOOL Name & Location of School:
*
Years Attended:
Date Graduated:
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Month
-
Day
Year
Date
Degree:
UNIVERSITY/ COLLEGE UNDERGRADUATE Name & Location of School:
*
Years Attended:
Date Graduated:
-
Month
-
Day
Year
Date
Degree:
Name & Location of School:
Years Attended:
Date Graduated:
-
Month
-
Day
Year
Date
Degree:
UNIVERSITY/ COLLEGE GRADUATE Name & Location of School:
Years Attended:
Date Graduated:
-
Month
-
Day
Year
Date
Degree:
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Employment History
Provide information on your last 2 employments.
#1
Employer:
*
Job Title:
*
Address:
*
Duties:
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Phone:
*
Format: (000) 000-0000.
Salary:
Date From:
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Month
-
Day
Year
Date
Date To:
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-
Month
-
Day
Year
Date
Reason for Leaving:
*
#2
Employer:
*
Job Title:
*
Address:
*
Duties:
*
Phone:
*
Format: (000) 000-0000.
Salary:
*
Date From:
*
-
Month
-
Day
Year
Date
Date To:
*
-
Month
-
Day
Year
Date
Reason for Leaving:
*
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Personal Preferences
*** Two reference letters are required. The personal references listed here must match the individuals who provide those letters.
#1
Name:
*
First Name
Last Name
Occupation:
*
Address:
*
Relationship:
*
Phone:
*
Format: (000) 000-0000.
Years Known:
*
#2
Name:
*
First Name
Last Name
Occupation:
*
Address:
*
Relationship:
*
Phone:
*
Format: (000) 000-0000.
Years Known:
*
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Physical Record
Do you have any physical disabilities that would prevent you from performing the work for which you are applying?:
*
yes
no.
If so, please describe:
Have you ever been injured?
*
yes
no
Provide Details:
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Additional Areas of Expertise
Areas of specializedstudy, research oradditional experience:
List the foreign languages you speak fluently:
Read:
Write:
U.S. Military Service:
Separation Rank:
Present Membership in National Guard or Reserves:
YES
NO
Emergency Contact Information
Name:
*
First Name
Last Name
Relationship:
*
Address
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I voluntarily give to the Agency the right to make a thorough investigation of my past employment. I agree to cooperate in such an investigation. I understand that my employment will be based in part on the accuracy of the information provided on this application
Employee Signature:
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