EMPLOYMENT APPLICATION Inquire about joining our team today Employment P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this document, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this document, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained.PAS 12/2017GLINN AND GIORDAN PHYSICAL THERAPYAPPLICATION FOR EMPLOYMENT We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regardto race, color, religious creed (all aspects of religious belief, observances and practices including religious dress and grooming practices), sex (pregnancy, breastfeeding, childbirth, and related medical conditions), national origin, ancestry, sexual orientation, age (over 40), marital status (including registered domestic partner status), gender identity, medical condition (as defined by law), including cancer and genetic characteristics, mental disability, physical disability, except where physical fitness is a valid occupational qualification, reproductive health decision making, domestic violence victim status or other status protected by State or Federal law, genetic information, gender expression, military and veteran status.Personal InformationName* First Middle Initial Last This field is hidden when viewing the formApplication DateAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Referred ByUPON OFFER OF EMPLOYMENT, VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES WILL BE REQUIRED.ARE YOU LESS THAN 18 YEARS OF AGE?* Yes No HAVE YOU EVER USED ANOTHER NAME?* Yes No DRIVERS LICENSE NUMBERStateExpiration DateDriving RecordEmployment DesiredDate Available* MM slash DD slash YYYY Salary DesiredPOSITION DESIRED OR AREA OF INTEREST*HAVE YOU EVER APPLIED TO THIS ORGANIZATION BEFORE?* Yes No PositionDate MM slash DD slash YYYY HAVE YOU EVER BEEN EMPLOYED BY OUR ORGANIZATION BEFORE?* Yes No Dates of EmploymentNAMES OF FRIENDS OR RELATIVES EMPLOYED BY THIS ORGANIZATIONARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING WITH OR WITHOUT REASONABLE ACCOMMODATION?* Yes No CAN YOU WORK OVERTIME? Yes No ARE YOU CURRENTLY EMPLOYED? Yes No IF SO, MAY WE CONTACT YOUR PRESENT EMPLOYER? Yes No EDUCATION/U.S. MILITARY SERVICEPLEASE INDICATE ANY LANGUAGES, OTHER THAN ENGLISH THAT YOUSpeakReadWriteEducationHigh SchoolMajorUNITS COMPLETED AND GRADE AVERAGEDEGREES AND/OR DIPLOMASCollegeMajorUNITS COMPLETED AND GRADE AVERAGEDEGREES AND/OR DIPLOMASCollegeMajorUNITS COMPLETED AND GRADE AVERAGEDEGREES AND/OR DIPLOMASOtherMajorUNITS COMPLETED AND GRADE AVERAGEDEGREES AND/OR DIPLOMASPROFESSIONAL CERTIFICATES OR LICENSES HELDARE YOU PRESENTLY TAKING ANY EDUCATIONAL COURSE? Yes No What and WhereMilitaryHAVE YOU EVER SERVED IN THE U.S. ARMED SERVICES? Yes No MILITARY DUTIES AND TRAININGPLEASE LIST JOB RELATED ORGANIZATIONS, CLUBS, PROFESSIONAL SOCIETIES, OR OTHER ASSOCIATIONS TO WHICH YOU BELONG –YOU MAY OMIT THOSE WHICH INDICATE YOUR RACE, RELIGIOUS CREED, COLOR, NATIONAL ORIGIN, ANCESTRY, SEX OR AGEREFERENCESPLEASE LIST THREE NON-RELATIVES WHO ARE QUALIFIED TO EVALUATE YOUR CAPABILITIESName*Address*Telephone*Occupation*Years Known*Name*Address*Telephone*Occupation*Years Known*Name*Address*Telephone*Occupation*Years Known*EMERGENCY INFORMATIONIn case of emergency, notifyName* First Last Telephone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMPLOYMENT HISTORYGIVE EMPLOYMENT RECORD AS COMPLETELY AS POSSIBLE, LISTING MOST RECENT EMPLOYMENT FIRST, INCLUDE EMPLOYED/SELF-EMPLOYED PERIODS AND PART-TIME OR SUMMER WORKCompany NameTelephoneLocationType of businessNAME OF SUPERVISORPOSITION(S) HELDREASON FOR LEAVINGDESCRIPTION OF DUTIESCompany NameTelephoneLocationType of businessNAME OF SUPERVISORPOSITION(S) HELDREASON FOR LEAVINGDESCRIPTION OF DUTIESCompany NameTelephoneLocationType of businessNAME OF SUPERVISORPOSITION(S) HELDREASON FOR LEAVINGDESCRIPTION OF DUTIESMAY WE CONTACT THESE EMPLOYERS? Yes No Comments1. I understand that if I am given a conditional offer for employment by this company, I will be required to submit to a pre-employment background screening. I authorize all corporations, companies, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts, military services and persons to release information they may have about me to the person or company with which this form has been filed, or their agent and release all parties involved from any liability and responsibility for doing so. I also authorize the procurement of an investigative consumer report and understand that it may contain information about my background, mode of living, character and personal reputation. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested. Further information may be available upon written request within a reasonable period of time. Check this box if you choose to waive your right to receive a copy of any public record obtained pursuant to California Civil Code section 1786.53. "Public records" means records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment. 2. I understand that if I am being considered for employment by this company, I will be required to submit to a post-offer physical and drug/alcohol testing (all of which will be paid for by this company) and to authorize the release of the physical examination and test results to this company. Applicants whose test results are positive (prohibited substances present) will not be eligible for further employment consideration.3. Any acceptance of employment will be predicated upon the truthfulness of the written and verbal statements contained within this Application and pre-employment process. I understand that should my employer find that any statement I have made is not truthful, any job extended to me may be withdrawn and, if employed, I may be subject to termination.4. I authorize the National Personnel Records Center, St. Louis, Missouri, or other custodian of my military records to release ,information or photocopies of my military personnel and related medical records, or only the following information/records. Service NumberBranch of serviceFrom MM slash DD slash YYYY To MM slash DD slash YYYY 5. I understand this Application for Employment is not to be confused as a guarantee of employment for a specific time. I further understand that my employment with this company does not constitute any form of contract, implied or expressed, and such employment will be terminable at will either by myself or my employer upon notice of one party to the other. My continued employment is dependent on satisfactory performance and the continued need for my services as determined by this organization.6. I grant my employer approval, after my termination of employment to release information which it may deem appropriate regarding my employment with or termination from the organization, to anyone who has a reasonable basis for making such inquiry. So long as the information disclosed is not known by this organization to be inaccurate, this organization shall not incur legal liability of any nature in connection with the furnishing of such information.I understand that my Application for Employment will be placed in an active status for a period of six months during which time it will be reviewed as job openings occur in my area(s) of job interest. I also understand that should I wish to continue being considered for job openings beyond the six month period, I must reapply by (a) submitting a new Application for Employment or by (b) submitting a letter requesting renewal of my Application and including an update of my qualifications (recent work history, educational achievements, etc.).8. I acknowledge that I have read all of the above statements and that I understand them.Applicant Signature*This field is hidden when viewing the formDate MM slash DD slash YYYY P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this document, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this document, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained. P•A•S 12/2017CAPTCHA
