Name (Last, First, Middle)               Street Address  

City, State               Zip Code  

Telephone              

Email Address 

Are you at least 18 years of age? No Yes Are you at least 16 years of age? No Yes
(If less than 16, can you furnish a work permit?) No Yes

Have you ever been employed here before? Yes No   If yes, give date  

Are you employed now? No Yes May we contact your present employer? No Yes

Can you, if hired, submit verification of your legal right to work in the U.S.? No Yes

On what date would you be available to begin work?  

Give name, address and telephone number of three references who are not related to you and are not previous employers.
 
 
 

Have you ever been convicted of a criminal offense other than a traffic violation? Yes No

Have you ever been convicted of abuse or neglect of a child or adult? Yes No

EDUCATION

Please list all education or specialized experience which you feel relates to the position(s) applied for and would help you, such as high school, college, business or technical schools.

Name and address  
Degrees & Achievements  

Name and address  
Degrees & Achievements  

Name and address  
Degrees & Achievements  

EMPLOYMENT HISTORY

Start with your present or last job. Include military service assignments and/or volunteer activities. Account for all periods of unemployment. Exclude organizations' names which indicate, for example, race, color, religion, sex, national origin or disability.

Employer name and address  
Date (Month/Year)   From     To     Rate of Pay  
Title of Job or Position(s) held  
Reason for Leaving  

Employer name and address  
Date (Month/Year)   From     To     Rate of Pay  
Title of Job or Position(s) held  
Reason for Leaving  

Employer name and address  
Date (Month/Year)   From     To     Rate of Pay  
Title of Job or Position(s) held  
Reason for Leaving  

APPLICANT'S STATEMENT

I certify that the answers given in the Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in this Application and I understand that any false or misleading information provided may result in my immediate discharge.

I understand that I will be required to fulfill all aspects of any job if I'm hired to perform the job. I understand that the failure to fulfill any aspect of the job may be grounds for termination. I also understand that I may be required to pass a physical therapy exam. I also understand that I may be required to take a physical examination after I am given a qualified offer of employment.

I understand that this Application is not a contract of employment; that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the facility is terminable at will; that I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if hired I am required to abide by all rules and regulations of the facility.

I understand and agree with the above statements. No Yes

EQUAL OPPORTUNITY EMPLOYER

Applicants are considered for, and employees are treated during employment, without regard to age, race, color, creed, pregnancy, sex, national origin, religion, disability or status as a disabled Vietnam-era veteran.

To submit your Employment Application Form, click below.