First Name*
Last Name*
Email Address*
Phone*
Cover Letter*
Who referred you to this position? Enter their first and last name here.
Desired salary
Earliest start date?
References: Please enter names and contact information:*
First and Last Name of Applicant:*
Phone Number:*
When is the best time to contact you at the above number?
Full Address:*
How did you hear about this position? Please name the source, website and/or name of the current employee who referred you.*
Are you currently employed?*
If you answered yes to the question above, may we contact your present employer?
Have you ever worked for Centrex Rehab or Augustana Therapy Services before? If so, please provide dates.
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 legally eligible to work in the United States and 16 years of age or older?*
Will you now or in the future require visa sponsorship for employment at Centrex Rehab?*
Have you graduated from an accredited OTA or PTA program?*
-- No answer -- Yes No
Are you currently licensed to work as a therapist?*
-- No answer -- Yes No
If you answered yes to the above question, in which state are you licensed?
How many years of experience do you have as a licensed therapist or certified therapy assistant?*
Has your license of certification ever been investigated or suspended?*
Have you ever been named as a defendant in a professional liability action?*
Previous Employment: Please list below your 3 most recent work experiences including: company name, job title, supervisor name, dates of employment, and reason for leaving.*
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.*
Education: Please list any Colleges/Universities you have attended, including the degrees earned and the dates they were obtained.*
Are there any 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 understand and agree that: *
I understand and agree that (continued):*
