Who referred you to this position?
LinkedIn Profile URL:
Earliest start date?
In 150 characters or fewer, tell us what makes you unique. Try to be creative and say something that will catch our eye!
References: Please enter names and contact information:
First and Last Name of Applicant:
When is the best time to contact you at the above number?
How did you hear about this position? Please name the source, website and/or the name of the current employee who referred you.
Have you ever worked for Centrex Rehab or Augustana Therapy Services before? If so, please note dates.
Are you currently employed?
* Yes No
If you answered yes to the question above, may we contact your present employer?
Have you applied with our company or Augustana Therapy Services before? If yes, please provide a date.
What are your pay requirements for this position?
When would you be available to start if you were offered this job?
If hired, can you furnish proof that you are eligible to work in the United States and 16 years of age or older?
* Yes No
Has your license of certification ever been investigated or suspended?
* Yes No
Have you ever been named as a defendent in a professional liability action?
* Yes No
If you responded "Yes" to either of the above questions, please attach a separate sheet with an explanation.
Are you currently licensed to work as a therapist? If yes, please specify the state for which you are licensed and provide your license #.
Previous Employment: Please list below your 3 most recent work experiences including: company name, job title, supervisor name, dates of employment, reason for leaving and your start and ending pay rates for each position.
May we contact any of your previous supervisors for a reference? Please provide contact information (e-mail and phone #).
Education: Please list the high school you attended, including the city and state of the school and the year of graduation.
Please list any Colleges or Universities you have attended, including the dates of attendance and the degrees earned.
Other related certifications, training or skills you would like to list.
Please list a minimum of 3 professional references. Include the company they work for, your relationship with them, and their contact information (e-mail and phone #).
Centrex Rehab is an equal employment opportunity employer and will not discriminate against any applicant or employee on any grounds protected under federal, state, or local law, including race, color, creed, religion, age, sex, sexual orientation, sexual harassment, national origin, ancestry, marital status, handicap, disability related to pregnancy or childbirth, membership or activity in any local commission, status regarding public assistance, membership or non-membership in any labor organization, or any other characteristic protected under federal, state or local law. None of the questions in this application are intended to elicit information regarding any protected characteristic protected under federal, state, or local law. None of the questions in this application are intended to elicit information regarding any protected characteristics, nor imply any limitation, illegal preferences, or discrimination based upon non-job-related information or protected characteristics. If you are hired by Centrex Rehab, you will be employed on an at-will basis. As an at-will employee, you may terminate your employment at any time for any reason, without notice. Similarly, if you are hired, Centrex Rehab will have the right to terminate your employment at any time, for any reason, without prior notice. No Centrex Rehab supervisor or manager has the authority to offer or promise anything other than at-will employment.
I have read and understand the above. * YES
I understand and agree that:
1. Any material misrepresentations or deliberate omission of a fact in my application may be justification for refusal of, or if employed, termination from employment.
2. By signing this application, I authorize Centrex Rehab to obtain and authorize all state, federal, or local law enforcement agencies or officials to release any and all information they have regarding any criminal convictions I may have, regardless of the date, location, or nature of the conviction. I understand that criminal conviction(s) will not automatically disqualify me from eligibility for employment with Centrex Rehab.
3. I agree that my employment may be terminated by Centrex Rehab at any time without liability for wages or salary except what may have been earned at the date of termination. If requested by the management at any time, I agree to submit to search of my person or of any locker that may be assigned to me, and I hereby waive all claims for damages on account of such examination. I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the duties of a job I am being considered for prior to employment or in the future during my employment with Centrex Rehab. I consent to take a medical examination by a qualified physician at the discretion of my employer.
4. Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift work, a rotating work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment.
5. I further understand that this is an application for employment and that no employment contract is being offered. * Yes
I understand and agree that (continued):
6. If applying, understand that some positions may be subject to a labor contract.
7. I acknowledge that: a) if I become employed, I will be free to terminate my employment at any time for any reason and Centrex Rehab retains the same rights; b) Centrex Rehab can change wages, benefits and conditions at any time; and c) no representative of Centrex Rehab has the authority to make any contrary agreement. I understand that Centrex Rehab is a drug-free work environment.
8. I understand that I am required to abide by all rules and regulations of Centrex Rehab.
9. I am not ineligible or excluded from participating in the Federal Health Care programs. * Yes
The following questions are entirely optional.
To comply with government Equal Employment Opportunity / Affirmative Action reporting regulations, we are requesting (but NOT requiring) that you enter this personal data. This information will not be used in connection with any employment decisions, and will be used solely as permitted by state and federal law. Your voluntary cooperation would be appreciated.
Decline to answer Female Male
Decline to answer White (Not Hispanic) African American/Black (Not Hispanic) Hispanic Asian Pacific Islander American Indian Native Alaskan Native Hawaiian Multi-racial
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
A “disabled veteran” is one of the following:
a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
OMB Control Number 1250-0005
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if
you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:
Multiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
Please check one of the boxes below:
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at
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