Application for Employment

Fill in the Application Form and Upload your resume here:

Name
First Last
Other names under which you have worked?
Present Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Mobile
Email
Can you, after employment, submit verification of your legal right to work in the U.S.?
- Yes
- No
Proof that you are at least 18 years of age?
- Yes
- No
Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodations?*
- Yes
- No
If necessary, please describe what type(s) of reasonable accommodations are needed
Person to be notified in an Emergency
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Position Applied for
Salary Requirements
Specify:*
- Full-Time
- Part-Time
- Resource (Per Diem)
Are you able to work overtime?
- Yes
- No
If Part-Time please specify days and hours:
Have you ever worked here before?
- Yes
- No
If yes, when?
How were you referred to us?
- Advertisement
- Employee
- Other
If other, please specify:
If an offer were extended, when would you be available for work?
(Please select ALL that apply)
- Outpatient Clinic
- Inpatient - Acute Floors
- Intermediate Care - DOU
- ICU - CCU
- Isolation Precautions
- Pediatrics
- Oncology
- Orthopedics
- Home Health
- Adult Day Programs
- Cardiac Rehabilitation
- Physician Practice
- Pulmonary Rehab
- Skilled Nursing Facility - TCU
- Wound Care
Other:
Please select ALL that apply
- DOS
- Windows
- Mac
- MS Word
- WordPerfect
- Lotus
- Excel
- MS Access
Other:
Typing Speed (wpm)
If it would be related to the job you are seeking, do you speak, read or write in any language other than English?
- Yes
- No
If yes, please describe
(Provide information applicable to position applying for)
Professional License No.
Type of License
Place of Issue
Expiration Date
MM slash DD slash YYYY
Has your license been revoked, suspended or cancelled?
- Yes
- No
If yes, by whom and when?
Membership(s) in Professional Organizations which may be applicable to the position you are applying for
Please provide professional references below (please do not list relatives)
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
EDUCATION
Name of School and address*
No. of Years*
Courses or Major*
Degree or Diploma*
College/University
Name of School and Address
No. of Years
Courses or Major
Degree or Diploma
Trade School
Name of School and Address
No. of Years
Courses or Major
Degree or Diploma
EMPLOYMENT HISTORY
Are you presently employed?*
- Yes
- No
May we contact your present employer?*
- Yes
- No
In order to verify information, please indicate the name under which you were employed if the name is different to your actual name.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title and Duties
Supervisor's Name and Position
Scheduled hours per week
Reason for Leaving
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Name of Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title and Duties
Supervisor's Name and Position
Scheduled hours per Week
Reason for Leaving
List ANY periods of unemployment during the past seven years beginning with the most recent. From, to, Reason for unemployment
Below, please write a brief paragraph detailing what you feel you can contribute to Interstate Rehab
Upon receiving an offer of employment, all candidates selected for any position must successfully complete a pre-placement background investigation and a medical examination including a test designed to detect the presence of illegal drugs, prior to the first day of employment. Interstate Rehab will hire only individuals who have the legal right to work in the U.S. in accordance with Federal Law. Please read the following CAREFULLY before signing this application form.
I understand that all offers of employment are conditioned on my successful completion of a criminal background investigation, a medical examination, a test designed to detect the presence of illegal drugs (I will disclose any legal drug use before a test is administered), on Interstate Rehab receipt of satisfactory proof of my identity and legal authority to work in the United Stated. Please read the following CAREFULLY before signing this application form.
PLEASE INITIAL:*
I understand that any misrepresentation, falsification or material omission of information may result in my failure to receive an offer or, if I am hired, in my immediate dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of Interstate Rehab and assigned facilities, as they may be amended, and agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of Interstate Rehab.
PLEASE INITIAL:*
I understand that no employee or representative of Interstate Rehab, other that the President of Interstate Rehab has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing. Further, the President of Interstate Rehab may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specified time unless the President of Interstate Rehab and I both sign a written agreement that clearly specifies the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no previous arrangements or oral or collateral agreements regarding this issue.
PLEASE INITIAL:*
YOUR FULL NAME*
Date
MM slash DD slash YYYY
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Application for Employment

EDUCATION

College/University

Trade School

EMPLOYMENT HISTORY