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(402) 483-0006 |
Fax:
(402) 483-0382
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Employment/Shadow Application
Your Information
First Name
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Last Name
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Address
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City
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State
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Zip Code
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Phone
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Email Address
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Employment Information
What position are you applying for?
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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
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Full Time
Part Time
Full or Part Time
Days and Times Available to Work
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Please list the days, start and end times you are available to work
How many hours would you prefer to work per week?
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1-5
6-10
11-20
21-30
31-40
Date you would be able to start:
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Previous Education
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Please list all High School, College, Business/Trade, Professional/Graduate school you have completed
What experiences/talents would you bring to this clinic?
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Previous Employment
Previous Employer 1
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Supervisor
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Employed From
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Employed To
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Position
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Weekly Hours
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Pay
*
Job Duty Description
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Reason for Leaving
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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
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Phone Number
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Email Address
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Reference 2 Name (First and Last)
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Relationship
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Phone Number
*
Email Address
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Reference 3 Name (First and Last)
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Relationship
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Phone Number
*
Email Address
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Attestation
Are you of legal age to work in the state of NE?
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Yes
Have you ever been convicted of a crime?
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No
Yes
Please explain in detail
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Questions
If you are applying for shadowing, an internship or a PT Tech position, please tell us
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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?
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Agreement
By signing below, I acknowledge that all of the above information is correct and truthful.
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