Index page

THERAPIST APPLICATION

Name
Email
Address 1
Address 2
City
State/Province
Zip/Postal Code
Phone #
Fax #

Best Time to Call		Morning Afternoon Evening

Specialty		PT PTA OT COTA SLP ST

College
Address
City
Current State Licenses Held
Country
Zip/Postal Code
Year of Graduation
Degree
Employment History 1
Most Recent Employer

Dates Employed (mm/dd/yy)		to

Address
City
State/Province
Country
Zip/Postal Code
Name of Supervisor

May We Contact This Employer?		Yes No

Position
Duties
Employment History 2
Most Recent Employer

Dates Employed (mm/dd/yy)		to

Address
City
State/Province
Country
Zip/Postal Code
Name of Supervisor

May We Contact This Employer?		Yes No

Position
Duties
Employment History 3
Most Recent Employer

Dates Employed (mm/dd/yy)		to

Address
City
State/Province
Country
Zip/Postal Code
Name of Supervisor

May We Contact This Employer?		Yes No

Position
Duties
Employment History 4
Most Recent Employer

Dates Employed (mm/dd/yy)		to

Address
City
State/Province
Country
Zip/Postal Code
Name of Supervisor

May We Contact This Employer?		Yes No

Position
Duties

Are You New York State Licensed?		Yes No In Progress

Do You Require H-1b Visa for Immigration?		Yes No
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. Any omission or misstatement of material fact on this application shall be grounds for rejection of this application or for immediate discharge if I am employed. Rehab Resources is an Equal Opportunity Employer.


	Rehab Resources' vision is to be the first choice of quality oriented therapists who have a passion for their work and are seeking challenging and rewarding settings.

Rehab Resources | 159 West First St. | Oswego, NY 13126
(315) 342-9575 (800) 342-9575 | FAX (315) 342-7664
email: ealberts@rehabresources.org