Pediatric to Geriatric Therapy
APPLICATION FOR EMPLOYMENT
This Agency does not discriminate. No applicant will be rejected because of race, color, national origin, disability, sex, or age.
Position applied for:
choose one
Occupational Therapist
COTA
Physical Therapist
PTA
Speech Pathologist
Administrative Assistant
Name:
Address
City/State/Zip
Home Phone
Cell Phone
E-mail address
Are you legally able to work in the U.S.?
Yes
No
What other languages do you speak?
EDUCATION
Give the name and location of last school attended and whether or not a diploma or a degree was obtained.
Name of school:
Location
Degree/Diploma
Years attended from
to
Name of school:
Location
Degree/Diploma
Years attended from
to
Name of school:
Location:
Degree/Diploma
Years attended from
to
OTHER TRAINING/LICENSES/CERTIFICATIONS:
WORK HISTORY (CURRENT OR MOST RECENT)
Employer name:
Address
City/state
Zip
Start date:
End date
Employer name:
Address:
City/state
Zip:
Start date
End date
Employer name
Address
City/state
Zip
Start date
End date
REFERENCES - PROFESSIONAL
Name
Address
City/state
Zip
Work #
Home #
Name
Address
City/state:
Zip
Work #
Home#
Name
Address
City/state
Zip
Work #
Home#
CONCLUDING STATEMENTS AND REQUESTED INFORMATION
I verify all statements contained in this application are true and accurate. I understand that misrepresentation or omission of facts is cause for dismissal. I understand that this employment application or possible interview does not constitute a contract of employment.
I Agree:
yes
Initials
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Central Rehabilitation
950 Office Park Road Suite 100
West Des Moines IA 50265
Phone 515-224-0979 ● 800-357-3422 ● Fax 515-223-3862
Children's Therapy Services
950 Office Park Road Suite 121
West Des Moines IA 50265
Phone 515-327-9222 ● 800-357-3422 ● Fax 515-327-9111