Employment/Shadow Application | Complete Physical Therapy

Your Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone *

Email Address *

Employment Information

What position are you applying for? *

Shadowing Experience for High School Credit

Shadowing Experience for College Credit

Interning Experience

Job - Physical Therapy Tech

Job - Office Staff

Job - Professional Staff

Employment Desired *

Full Time

Part Time

Full or Part Time

Days and Times Available to Work *

Please list the days, start and end times you are available to work

How many hours would you prefer to work per week? *

Date you would be able to start: *

Previous Education *

Please list all High School, College, Business/Trade, Professional/Graduate school you have completed

What experiences/talents would you bring to this clinic? *

Previous Employment

Previous Employer 1 *

Supervisor *

Employed From *

Employed To *

Position *

Weekly Hours *

Pay *

Job Duty Description *

Reason for Leaving *

Previous Employer 2

Supervisor

Employed From

Employed To

Position

Weekly Hours

Pay

Job Duty Description

Reason for Leaving

Previous Employer 3

Supervisor

Employed From

Employed To

Position

Weekly Hours

Pay

Job Duty Description

Reason for Leaving

References

Reference 1 Name (First and Last) *

Relationship *

Phone Number *

Email Address *

Reference 2 Name (First and Last) *

Relationship *

Phone Number *

Email Address *

Reference 3 Name (First and Last) *

Relationship *

Phone Number *

Email Address *

Attestation

Are you of legal age to work in the state of NE? *

Have you ever been convicted of a crime? *

Please explain in detail *

Questions

If you are applying for shadowing, an internship or a PT Tech position, please tell us *

1. Why are you interested in the field of Physical Therapy? 2. What do you hope to gain from the experience? 3. What are your short and long term educational and career goals?

Why do you believe you would be a great addition to our clinic? What skills or talents set you apart from other applicants? *

Agreement

By signing below, I acknowledge that all of the above information is correct and truthful.

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