APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION
Name (Last, First, Middle Initial): Date: / /
Address:
City: State: Zip:
Phone: ( ) Social Security No.:
Classification: License No.: Expiration: / /
If employed by Pillars Physical Therapy and Wellness Center, what date are you available to begin work? / /
If you are not a U.S. citizen, do you have legal right to work in the U.S.? yes no
Is there any reason you would be unable to safely perform the essential duties of the job for which you are applying (as described in the job description)? yes no
EMPLOYMENT RECORD Please list 3 most recent employers-Nursing positions only
Employer No.1:
Phone: ( ) Supervisor:
Job Title:
From: / / To: / /
Duties:
Reason for leaving: Salary: $ /hour
Employer No.2:
Employer No.3:
EDUCATION RECORD Please include all post high school education. List most recent schools first.
School No.1: Type:
Degree: Graduated? yes no
School No.2: Type:
PROFESSIONAL REFERENCES List two MOST RECENT supervisors or others who are familiar with your work performance.
Name: Phone: ( )
PERSONAL REFERENCES (at least one) Reference can attest to your character and whom you have known at least five years.
HAVE YOU EVER BEEN CONVICTED OF A FELONY WITHIN THE PAST 7 YEARS? (A CONVICTION RECORD IS NOT NECESSARILY A BAR TO EMPLOYMENT. EACH CASE WILL BE GIVEN INDIVIDUAL CONSIDERATION) yes no
EMERGENCY INFORMATION
Employee's Name: Date: / /
In case of emergency, please notify:
Name:
Phone: ( ) Relationship:
AND/OR
