Employment Application

Professional Therapy Associates,LLC
Application For Employment

Please print or type: The Application must be fully completed to be considered
Please complete each section, even if you attach a resume.

Personal Information

Name:

Birthdate:

Address:

Social Security No:

City:

State:

Zipcode:

Phone:

Email:

Are You Legally Eligible to Work in US ?

Yes

If Selected For Employment are you willing to submit a background check ?

Yes

Do you have a valid drivers license and reliable transportation ?

Yes

Position

Position you are applying for:

Available Start Date:

Desired Pay:

Employment Desired:

Part-time

Full-time

Seasonal/Temporary

Upload Resume:

Education

Please list any educational experinces that you have had beginning with High School

School	Location	Year(s) Attended	Degress Received

Licences/Certification

Please list any Licences and/or certification that you hold

Title	Number	Date Issued	Renewal Date

Availability

Please list the shift you are willing and able to work for each day of the week

Employment History

Please list your last employers,if applicable

Company Name	Job Title	Dates Employed	Address	Phone	May we contact Them ?

References

Please provide three references that we may contact

Name	Relationship	Phone No.	Time Known

Signature Disclaimer

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. I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer’s service, whenever it is discovered. I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information. The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer, other than an authorized officer, has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of that’s person’s need for a reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

(Required) Please type owner's Legal First and Last Name below *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree that I have typed my name and checked the box myself. *
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