Who referred you to this position?
LinkedIn Profile URL:
Earliest start date?
Have you ever been convicted of a felony?
No answer No Yes
If “Yes”, you have been convicted of a felony, please explain the circumstances around the conviction:
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