It is the policy of this company to provide equal opportunities without regard to race, color, religion, sex, national origin, age, disability or any other reason prohibited by law.
Position you are applying for: FT PT PRN
Today is . Your application will be kept for one year.
Days and times available to work:
Date you can begin work:
Salary Requirements:
Name (First MI Last):
Email: We will not sell or share your information with anyone. Your email will be used only in relation to this application or inquiry.
Phone:
Social Security Number: Why do we need this?
Current Street Address:
City: State: Zip:
I need to provide an alternate or permanent mailing address
I am over 18 years old.
I am a U.S. Citizen or legally authorized to work in the U.S.
I have read the job description and I meet the qualifications and have the ability to perform the essential job functions of this job
--NoYes Have you been convicted of or plead guilty to a criminal felony offense other than traffic violations in the past 7 years?
Please explain the offense:
--NoYes Have you been excluded from participation in federal or state health care programs?
--NoYes Have you ever been employed by Restore Professionals Company, LLC?
Provide position and dates employed:
Special skills you possess pertinent to your profession:
Long-range occupational goals:
How were you referred to Restore? Internet ad Restore website Conference Employee Referral Postcard or flier Phone call to home Phone call to home PRN upgrade Reinstatement
The amount of education considered necessary will vary according to job applied for.
Name, City, State:
Highest level completed: Graduated GED Junior Year Sophmore Year
Name, City, State: When:
Degree or Major:
Add another College or University
Speech / Audiology: CFY CCC-SLP CCC-A
ASHA Certification Number:
Current State License Numbers (State, Lic. #):
Physical Therapy: PT PTA
Occupational Therapy: OTR COTA
AOTA Certification Number:
List current and all previous jobs you have held
Employer: When (i.e. 1/2001 - 3/2004):
Hourly Rate or Salary Range:
Address: (Street, City, State ZIP)
Telephone Numbers:
Job Title: Supervisor:
Work Performance:
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I have a Military Service Record
The hiring and re-employment of veterans will be conducted in accordance with applicable state and federal laws and regulations.
I am currently a member of a Reserve or National Guard Unit
What brand of the Armed Forces:
Type of discharge:
Dates of duty (i.e. 3/1987 - 7/1992):
List duties in military or special training that prepared you for the position you are seeking:
By filling out this application I agree and consent to the terms of this application
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Restore Therapy Services, Ltd. uses your SSN to verify employment eligibility. We value your privacy. Your SSN is used for the purpose of this application only. We will protect your SSN from any unauthorized use.