Physical Therapist Job Application

Personal Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Social Security Number

Date Available to Start Work

YYYY

Desired Annual Pay

Employment Desired

Full-Time

Part-Time

Seasonal

Employment Eligibility

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S?

HAVE YOU EVER WORKED FOR THIS EMPLOYER?

*IF YES, WRITE THE START AND END DATES:

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

IF YES, PLEASE EXPLAIN:

Education

Name of High School

High School City & State

Graduation Date

YYYY

Name of College

College City & State

Did you Graduate?

What did you major in?

If you would like to add other colleges, please list information.

Please list college, City & State, Graduation Date & Degree Earned.

Previous Employer

Previous Employer Name

Company/Individual

Previous Employer Email

Previous Employer Phone

(###)

###

####

Job Title

Start Date with Previous Employer

YYYY

End Date with Previous Employer

YYYY

Reason for Leaving

Previous Employer #2

Please include previous employer name, email, phone, address, job title, start & end date, reason for leaving.

Previous Employer #3

Please include previous employer name, email, phone, address, job title, start & end date, reason for leaving.

References

Reference #1 Name

First Name

Last Name

Reference #1 Email

Reference #1 Phone

(###)

###

####

Reference #2 Name

First Name

Last Name

Reference #2 Email

Reference #2 Phone

(###)

###

####

Reference #3 Name

First Name

Last Name

Reference #2 Email

Reference #3 Phone

(###)

###

####

Military Service

Are you a Veteran?

If Yes, what branch?

First Name

Last Name

If Yes, what was your rank at discharge?

First Name

Last Name

Military Date: Start - Discharge

Type of Discharge

If not Honorable, please explain.

Background Check Consent

IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK?

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered. Please complete each section EVEN IF you decide to attach a resume. I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

I UNDERSTAND

Please Type FULL NAME: