Employment Application

Employment Application
About You
Name*

First NameLast Name
Email**
Cell Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position
Position you are applying for:**
Desired Salary*
Are you interested in:**
What schedule would you prefer?**

WeekdaysWeekendsEveningsNights
How did you hear about this position?**

Classified AdRadioInternetFriend
Who should we thank for recommending us?

Work Availability
When are you available to start work?*

MonthDayYear
Date
Are you authorized to work in the United States?**

YesNo
Are you under 18 years of age?**

YesNo
Can you furnish a work permit?**

YesNo
Are you capable of performing the essential functions of the job for which you are applying with or without a reasonable accommodation.**

YesNo
Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, Allied Physical Therapy will verify the status of every individual offered employment with the Company. In this connection, all offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization.

Allied Physical Therapy is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, Allied Physical Therapy complies with applicable state and local laws governing nondiscrimination in employment in every jurisdiction in which it maintains facilities. Allied Physical Therapy provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

Work Experience
Please tell us about your work experience, starting with your current or most-recent employer. Please attach your CV using the Browse Files button below. You must fill in your work experience on this form, even if it is also contained in the CV.
Please check below if you have no prior work experience

I have no prior work experience
Attach your CV

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Most Recent Work Experience
Company Name*
Your position or title*
State Date

MonthDayYear
Date
Starting Salary*
End Date

MonthDayYear
Date
Ending Salary*
Major Job Duties*
Briefly describe the major duties and skills required in your current or former position.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone

Area CodePhone Number
Supervisor's Name

First NameLast Name
Termination*

VoluntaryInvoluntary
Reason for termination*
Please tell us the circumstances surrounding your departure from your former position.

Previous Experience 1 (if applicable)
Company Name*
Your position or title*
State Date

MonthDayYear
Date
Starting Salary*
End Date

MonthDayYear
Date
Ending Salary*
Major Job Duties*
Briefly describe the major duties and skills required in your current or former position.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone

Area CodePhone Number
Supervisor's Name

First NameLast Name
Termination*

VoluntaryInvoluntary
Reason for termination*
Please tell us the circumstances surrounding your departure from your former position.

Previous Experience 2 (if applicable)
Company Name*
Your position or title*
State Date

MonthDayYear
Date
Starting Salary*
End Date

MonthDayYear
Date
Ending Salary*
Major Job Duties*
Briefly describe the major duties and skills required in your current or former position.
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone

Area CodePhone Number
Supervisor's Name

First NameLast Name
Termination*

VoluntaryInvoluntary
Reason for termination*
Please tell us the circumstances surrounding your departure from your former position.

Education
High School or Prep School Name**
High School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major Subject**
Did you Graduate?**

YesNo
College Name
College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major Subject
Did you Graduate?

YesNo
Type of Degree or Diploma
College or Graduate School Name
Grad School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major Subject
Did you Graduate?

YesNo
Type of Degree or Diploma
Other Education Name
Other Education Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major Subject
Did you Graduate?

YesNo
Type of Diploma or Certificate

Professional Designations
Please provide your professional designations along with the granting organization and completion dates, if applicable.

Designation 1 (if applicable)
Designation
Organization Granting Designation
Date Completed

MonthDayYear
Date

Designation 2 (if applicable)
Designation
Organization Granting Designation
Date Completed

MonthDayYear
Date

Section End
Professional Licenses
Please provide your professional licenses, and states where active, if applicable.

License 1 (if applicable)
Type of License
State Granting License
License Number

License 2 (if applicable)
Type of License
State Granting License
License Number

Section End
References
Please list three professional references. This section is required.

Reference 1 (required)
Name*

First NameLast Name
Relationship*
Company*
Phone Number*

Area CodePhone Number

Reference 2 (required)
Name*

First NameLast Name
Relationship*
Company*
Phone Number*

Area CodePhone Number

Reference 3 (required)
Name*

First NameLast Name
Relationship*
Company*
Phone Number*

Area CodePhone Number

Section End
Sign
By typing your full name in the space below, you are certifying that all of the information recorded in this employment application is true and correct.
Signature*
Please verify that you are human*
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About You

Position

Work Availability

Work Experience

Education

Professional Designations

Professional Licenses

References

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