Jackson Physical Therapy: Employment Application

Current positions available:

Application for Employment: Pre-employment Questionnaire (Equal Opportunity Employer)

Personal Information

Name:	Social Security Number:	Date:
Address:	City:	State:	Zip Code:
Phone Number:	Secondary Phone Number:	Referred By:

Employment Desired

Position:	Date you can start:	Salary Desired:
Are you employed now? Yes No	If so, may we inquire of your present employer? Yes No	Are you legally authorized to work in the U.S.? Yes No
Ever applied to this company before? Yes No	Where?	When?

Education History

	Name & Location of School	Years Attended	Did You Graduate	Subjects Studied
High School			Yes No

General Information

Subject of Special Study/Research Work
Special Training
Special Skills
U.S. Military or Naval Service		Rank

Former Employers (List below last four employers, starting with last one first)

Date/Month and Year	Name & Address of Employer	Salary	Position	Reason for Leaving
From: To:
From: To:
From: To:
From: To:

References (Give below the names of three persons not related to you,
whom you have known at least one year.)

Name	Address	Business	Years Known

Authorization

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorized investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, inless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohebited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

By checking the checkbox, I agree to the above.
I agree