Employment Application Form

Application For Employment

Name:*

First NameLast Name

Phone Number:*

Area CodePhone Number

E-mail Address:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How were you referred to us?*

Online AdEmployeeOther

Please specify where you saw the ad / indicate employee name / or other reason:*

Attach Cover Letter*

Browse Files

Attach Resume*

Browse Files

Position Applying For:*

If applying for a Physical Therapist or a Physical Therapist Assistant position, do you have Hawaii licensure?*

YesNoNot Applicable

Date available to work:

Date

Type of employment desired:

Full TimePart TimeOn-Call

How many hours can you work weekly?

We are open from Monday to Friday, all day and on Saturday mornings. What days are you available to work?

Have you previously applied for a job with Fukuji & Lum Physical Therapy?

NoYes (If yes, when?)Other

Education

High School:*

Years Completed:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

College/University:*

Degree and Major:

DegreeMajor

Years Completed:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other School:

Degree and Major:

DegreeMajor

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment History

Employer - Most Recent:*

EmployerPhone

Job Title:*

Employment Dates:*

Start DateEnd Date

Immediate Supervisor:*

Reason For Leaving:*

Employment History

Employer 2:

EmployerPhone

Job Title:

Employment Dates:

Start DateEnd Date

Immediate Supervisor:

Reason For Leaving:

Employment History

Employer 3:

EmployerPhone

Job Title:

Employment Dates:

Start DateEnd Date

Immediate Supervisor:

Reason For Leaving:

Have you ever been asked to resign?*

NoYes

If Yes, specify circumstance.

Job Skills & Training

Summarize any skills and experienes not previously listed that may further qualify you for this position.:

Please list any training or certifications:

Professional References

Please list three (3) references.

Reference 1 - Name:*

First NameLast Name

Relationship:*

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 2 - Name:*

First NameLast Name

Relationship:*

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 3 - Name:*

First NameLast Name

Relationship:*

Phone Number*

Area CodePhone Number

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Certification

I authorize investigation on all statements contained in this application. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.
I give Fukuji & Lum authorization to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of information contained in this application. I also release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information.
This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of Fukuji & Lum, other than an authorized officer, has the authority to make any assurances to the contrary.
I understand and agree that if I am hired, I will be required to provide proof of identity and legal work authorization. If offered a position with financial and/or managerial responsibilities by Fukuji & Lum, I may be required to disclose pending arrest information and criminal conviction information in accordance with the law, and that any such employment offer shall be dependent upon the receipt of a satisfactory arrest and/or conviction record as determined by Fukuji & Lum.

Acknowledgment

I have read, understand and agree that all of the above terms will apply should I be hired, and I seek employment with Fukuji & Lum Physical Therapy under these conditions.

Signature*