Look UP Therapy Job Application General

Look UP Therapy Job Application

Look Up! Therapy is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.
Applicant Information:

Please fill out all the sections below
Name

First Name Last Name
Date of birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Date of application

Month Day Year
Date

Employment Position
Position you're applying for:

Registered Behavior Technician BCBA Occupational Therapist Speech Pathologist Other
How did you hear about this position?
Desired pay rate:
What days are you available for work?
What hours or shifts are you available for work?
On what date can you start working if you are hired?

Month Day Year
Date
Do you have reliable transportation for work?

Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying:
Note: Look Up! Therapy LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)
Do you have a valid certification/license specific to your job title?

Yes No N/A
NPI # (if applicable):
Medicaid ID # (if applicable):
Education and Training

Highschool

	Name	Location (city/state)	Year Graduated	Degree Earned
1.
2.

College/University

Vocational School/Specialized Training

	Reference Name	Reference Position	Reference Phone Number
1.
2.

Medical History

Due to COVID-19, it is important that you give a true and full account of any medical problems when asked. If the answer toany of the following questions is “Yes” please give details

Health Questions

	Yes	No	If yes give details and dates here
Health Question
Do you have any illness, impairment, disability (physical or psychological) which may affect your work?
Have you ever had any illness, impairment, or disability which may have been caused or made worse by your work?
Are you having or waiting for treatment (including medication) or investigations at present?
Do you need any specific aids or adaptations to assist you at work whether you have a disability, including any hearing or visual aids?
Do you have any allergies which may be made worse by work e.g. latex?
A close family member/friend with whom you share a home diagnosed with TB
Have you lived continually in the US for the last 5 years
Is this your first job in Florida?
Have you or anyone in your household been exposed to COVID-19

Please submit this employment application with your resume and cover letter
Browse Files

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Please submit your certification/license (RBT/BCBA/SLP/OT)
Browse Files

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Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature *

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Look UP Therapy Job Application