Application for Employment

Application for Employment

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, martial or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER
Position(s) Applied For *
Type the Position Name
Date of Application *

Month Day Year
Today's Date
How did you learn about Western Berks Physical Therapy?
Choose one from the dropdown
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
If you are under 18 years of age, can you provide required proof of your eligibility to work? *

Yes No Over 18 Years of Age
Have you ever filed an application with us before? *

Yes No
Have you ever been employed with us before? *

Yes No
Are you currently employed? *

Yes No
May we contact your present employer? *

Yes No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? *

Yes No
On what date would you be available for work? *

Month Day Year
Select Date
Are you available to work: *

Full-time Part-time Temporary
Are you currently on "lay-off" status and subject to recall? *

Yes No
Can you travel if the job requires it? *

Yes No
Have you been convicted of a felony within the last 7 years? *
If Yes, please explain in box above. Conviction will not necessarily disqualify an applicant from employment.
EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related, military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.
Most Recent Employer Name *
Most Recent or Present Employer
Employer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title *
Date of Employment Start *

Month Day Year
Choose the day you started working for this employer.
Date of Employment End *

Month Day Year
Choose the day you stopped working for this employer. Pick today's date if still employed.
Reason for Leaving *
Type N/A if still employed
Hourly Rates/Salary
My starting salary was starting dollars per hour* per hour and my ending salary was ending dollars per hour per hour.
Describe the work performed at this job: *
2nd Most Recent Employer Name *
2nd Most Recent Employer
Employer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title *
Date of Employment Start *

Month Day Year
Choose the day you started working for this employer.
Date of Employment End *

Month Day Year
Choose the day you stopped working for this employer. Pick today's date if still employed.
Hourly Rates/Salary
My starting salary was starting dollars per hour* per hour and my ending salary was ending dollars per hour per hour.
Reason for Leaving *
Type N/A if still employed
Describe the work performed at this job *
3rd Most Recent Employer Name *
3rd Most Recent Employer
Employer Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title *
Date of Employment Start *

Month Day Year
Choose the day you started working for this employer.
Date of Employment End *

Month Day Year
Choose the day you stopped working for this employer.
Hourly Rates/Salary
My starting salary was starting dollars per hour* per hour and my ending salary was ending dollars per hour per hour.
Reason for Leaving *
Describe the work performed at this job *
4th Most Recent Employer Name
4th Most Recent Employer
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Job Title
Date of Employment Start

Month Day Year
Choose the day you started working for this employer.
Date of Employment End

Month Day Year
Choose the day you stopped working for this employer.
Hourly Rates/Salary
My starting salary was starting dollars per hour per hour and my ending salary was ending dollars per hour per hour.
Reason for Leaving
Describe the work performed at this job
If you have additional work experience that you would like considered, you may submit your full resume by email to wbptadmin@comcast.net after submitting this Application for Employment.
Special Skills or Qualifications
EDUCATION EXPERIENCE
Highest Schooling Level Completed *
Number of Years of Schooling Completed *
High School Name
High School Location - City and State
Undergraduate College/University Name
Leave blank if not applicable
Undergraduate College/University Location - City and State
Leave blank if not applicable
Describe Course of Study for Undergraduate College/University
Leave blank if not applicable
Graduate College/University Name
Leave blank if not applicable
Graduate College/University Location - City and State
Leave blank if not applicable
Describe Course of Study for Graduate College
Leave blank if not applicable
Describe any specialized training, apprenticeship, skills and extra-curricular activities:
Describe any honors you have received:
State any additional information you feel may be helpful to us in considering your application:
Indicate any foreign languages you can speak, read, and / or write.

For the foreign languages you indicated above, please select your fluency level in reading, writing and speaking the language.

Fluent

Good

Fair

Speak

Read

Write

List any professional, trade, business or civic activities and offices held. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.
REFERENCES

Give names, addresses and telephone numbers of 3 people who are not related to you that we may contact. Previous employers are helpful.
Reference 1 Name *

First Name Last Name
Reference 1 Phone Number: *
Please enter a valid phone number.
Reference 2 Name *

First Name Last Name
Reference 2 Phone Number: *
Please enter a valid phone number.
Reference 3 Name *

First Name Last Name
Reference 3 Phone Number: *
Please enter a valid phone number.
Have you ever had any job-related training in the United States military? If yes, please describe: *
Are you physically or otherwise unable to perform the duties of the job for which you are applying? *
APPLICANTS SIGNATURE
PLEASE READ AND UNDERSTAND THIS STATEMENT BEFORE SIGNING AND SUBMITING YOUR APPLICATION.

The information I have provided in this Application for Employment is true, correct and complete. False, incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and ontain information about me from previous employers, educational institutions and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in 90 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new appliation.

This application is not an employment agreement. If I accept an offer of employment, I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an executive officer of the employer, has authority to enter into any empliyment agreement with terms contrary to the foregoing and then only in writing signed by such officer.
I FULLY UNDERSTAND AND ACCEPT ALL TERMS AND CONDITIONS IN THE ABOVE STATEMENT. *

Yes No
Today's Date *

Month Day Year
Select Date
Signature *

Clear
Should be Empty:

Application for Employment

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT EXPERIENCE

EDUCATION EXPERIENCE

REFERENCES

APPLICANTS SIGNATURE