Timeless Therapy

THERAPIST - ONLINE APPLICATION FOR EMPLOYMENT

Upon submission of the online application you will be supplied by email a security Username and Password to access all other documentation needed to complete the application process.

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUESTIONNAIRE - EQUAL OPPORTUNITY EMPLOYER

PERSONAL INFORMATION

DATE:

NAME (LAST NAME FIRST): SOCIAL SECURITY NO:

PRESENT ADDRESS: CITY: STATE: ZIP:

PERMANENT ADDRESS: CITY: STATE: ZIP:

TELEPHONE: REFERRED BY:

EMAIL ADDRESS: (Email address required to submit employment application)

DESIRED POSTION

POSITION: DATE YOU CAN START: SALARY DESIRED:

ARE YOU EMPLOYED? YES NO IF SO, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER? YES NO

EVER APPLIED TO THIS COMPANY BEFORE? YES NO WHERE? WHEN?

EDUCATION HISTORY

NAME & LOCATION OF SCHOOL	YEARS ATTENDED	DID YOU GRADUATE?	SUBJECTS STUDIED
GRAMMER SCHOOL		YES NO
HIGH SCHOOL		YES NO
COLLEGE		YES NO
TRADE, BUSINESS OR CORRESPONDENCE SCHOOL		YES NO

GENERAL INFORMATION

SUBJECTS OF SPECIAL STUDY/RESEARCH WORK OR SPECIAL TRAINING/SKILLS

U.S. MILITARY OR NAVAL SERVICE RANK:

FORMER EMPLOYERS

DATE MONTH & YEAR	NAME & ADDRESS OF EMPLOYER	SALARY	POSITION	REASON FOR LEAVING
FROM:
TO:
FROM:
TO:
FROM:
TO:
FROM:
TO:

REFERENCES
GIVE BELOW THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR

NAME	ADDRESS	BUSINESS	YEARS KNOWN

AUTHORIZATION
     "I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
     I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.
     I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.
     THIS WAIVER DOES NOT PERMIT THE RELEASE OR USE OF DISABILITY-RELATED OR MEDICAL INFORMATION IN A MANNER PROHIBITED BY THE AMERICANS WITH DISABILITIES ACT (ADA) AND OTHER RELEVANT FEDERAL AND STATE LAWS."

I AGREE TO THIS AUTHORIZATION (CHECK BOX MUST BE CHECKED OR APPLICATION WILL NOT BE SUBMITTED)

DATE: DIGITAL SIGNATURE:

Miami-Dade Tel: 305.405.6585 - Fax: 305.405.6584 | Broward Tel: 954.454.2345 - Fax: 954.457.8242
2710 Van Buren Street, Hollywood, FL 33020