Employment Application

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All information will be keep private and secured. All applications will keep on our file within 60 days. We reserved the rights to screen all our future employee prior to hiring.

Physical Therapist - Must have a 4 year degree on this field, training program required, 1 to 2 year experience, must have a good transportation, people person, multi-tasking, long hours, computer literate.

Receptionist - Must have any of the following; Diploma, GED, degree, certificate, training program. A people person and must be good with customers, multi-tasking, computer literate, must be good answering phone calls, scheduling patients, cleaning, paperwork (filing) must have a good transportation.

Please give us time to review your application and after we made our decision about your future at Dupont Physical Therapy, we will give you a call and set you up with an interview. In the case you don't hear from us, please go to our contact information page and use the information that we provided.

COMPLETE THE FORM - ANSWER ALL QUESTIONS - PLEASE TAKE YOUR TIME
Dupont Physical Therapy is in compliance with Federal and State equal employment opportunity laws. qualified applicant's are considered for all positions without regard to race, color, religion, sex, national origin, age, military status, or disability, as defined by federal and state law.
Please complete the form and submit. All personal information we received will be put on file and will be keep privately and secured. We strongly suggest that you read our Privacy Policy before you begin your submission of your personal information.

GENERAL INFORMATION

Date of Application:
Referral Source:
Have you applied or worked at DPT before?	Yes No


PERSONAL INFORMATION

First Name:
Middle Initial:
Last Name:
Street Address:
City:
State or Province:
Zip Code:
Country:
Phone:
Email Address:
Social Security No:
Alien Registration No:
In case of accident or emergency, notify:
	CHECK IF APPLICABLE
Under 21?	if yes, list date of birth:
Are you a citizen of the U.S.?	Yes No
If no, do you have a legal right to remain and work in the U.S.? Yes No
Are you a veteran?	Yes No
If yes, what was your branch of military service Rank:

During the past 5 years, have you ever been convicted of a crime, not including misdemeanors and traffic violation?
	Yes No
If yes, briefly describe:

EMPLOYMENT DESIRED

Position you are applying for:
	Full Time:
	Part Time:
This job requires, among others the close contact or working with patient that might have low resistance or might be susceptible to communicable diseases. Do you have any infectious or communicable diseases or condition which would interfere with your ability to do this? Yes No
	If yes, please explain:

Do you have any reason to believe that you could not perform the essential functions of the job for which you are applying for?
	Yes No
	If yes, please explain:


EDUCATION OR SCHOOL CREDENTIAL
	HIGH SCHOOL
School Name:
Address or Location:
Check last year completed:	1 2 3 4
Studies:
Graduate?	Yes No

	COLLEGE
College Name:
Address or Location:
Check last year completed:	1 2 3 4 5 6 7
Major:
Graduate?	Yes No Degree:

	OTHER
School Name or Training Program:
Address or Location:
Check last year completed:	1 2 3 4
Major:
Graduate:	Yes No
Masters:

EMPLOYMENT EXPERIENCE

List each job held. Start with your present or last job. Including military service and volunteer activities.

	EMPLOYER 1
Company Name:
Address:
Date Employed:
Hourly rate or Salary:
Job Title:
Work Performed:
Supervisor:
Reason for Leaving:

	EMPLOYER 2
Company Name:
Address:
Date Employed:
Hourly rate or Salary:
Job Title:
Work Performed:
Supervisor:
Reason for Leaving:

	EMPLOYER 3
Company Name:
Address:
Date Employed:
Hourly rate or Salary:
Job Title:
Work Performed:
Supervisor:
Reason for Leaving:

REFERENCES

Give name, address, and phone number of three references not related to you.

	REFERENCE 1
Name:
Address:
Telephone:

	REFERENCE 2
Name:
Address:
Telephone:

	REFERENCE 3
Name:
Address:
Telephone:

APPLICANT'S STATEMENT

	By checking this box, I certify to the best of my knowledge are true and correct. I understand that falsification of this information could lead to termination of employment at Dupont Physical Therapy. I understand that this application is not to be a contract of employment, and my employment is at-will and is no definite period of time, and as such, either Dupont Physical Therapy or I may terminate the employment relationship with or without cause at any time.

Your Name:	Date:

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