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ADVANTAGE REHAB HOME CARE SERVICES INC.
Personal/Confidential
First Name
*
Middle Name
*
Last Name
*
Home Phone
*
Other Phone
Email
Home Address
*
Social Security No:
*
Driver's License No:
*
Position being applied for:
*
Physical Therapist
PT Assistant
Occupational Therapist
Certified OT Assistant
Speech Therapist
Type:
*
Full Time
Part Time
Contract Worker
Salary Desired $:
*
Education
School:
*
High School
College/University
Vocacional/Business
Name and Location:
*
No of years Completed:
*
Did you graduate?:
*
YES
NO
Degree or Diploma:
*
Employment History
Employer:
*
Position:
*
Time Period:
*
Supervisor:
*
Phone Number:
*
Reason You Left:
*
Did you work for any of these employers under a different name?:
*
YES
NO
Employer:
Name you Worked Under:
What languages can you speak other than english?
ADVANTAGE REHAB HOME CARE SVC., INC. (ARHCSI) is an Equal Opportunity Employer and does not discriminate on the basis of race, color, sex, age, religion, citizenship, national origin, marital status, disability, sexual orientation, or any other basis protected by applicable federal, state, or civil rights law.
Did you have Professional Liability Insurance?:
*
YES
NO
Car Insurance Carrier
References (3 References)
Name
Phone Number
Address
*
I understand that this application is not intended in any way to constitute an expressed or implied contract of employment. I further understand that, unless otherwise stated in a written agreement, my employment may be terminated with or without cause and with or without notice, at any time at the option of or myself, and that this right may be modified in a written agreement signed by an officer of ARHCSI.I hereby certify that all information I have supplied in this application is correct and complete. Except as otherwise provided above, I give ARHCSI permission to contact any or all of my previous employers or references for full information. Furthermore, I release from all liability and responsibility all persons and entities requesting or supplying information about my employment experience listed in this application, including my present employers. I understand that any falsification of information will constitute grounds for immediate dismissal upon discovery thereof.