Section 1: Personal Information *

Section 2: Job Related Information *

Section 3: Education

Section 4: License/Certification

Section 5: Employment History

List your work experience below starting with your present or most recent employer for the last 5 (five) years or your last 3 (three) employers, whichever will provide us with the greatest information about you. Please account for all periods of employment in this section.

Section 6: References

Section 7: Additional Skills

Section 8: Agreements *

Were you referred by someone?

Yes

No

Name

Disclaimer *

I agree to the following: Any misstatement, misleading information, or omission of information called for in this application, or other company records will result in the rejection of this application, the withdrawal of any other offer of employment and if employed, may result in discharge at any time upon or after the discovery.” I understand that if employed, I will be an employee-at-will and that I can voluntarily end my employment or be terminated at any time for any reason or no reason at all. No statement, whether written or oral, by any company representative other than a signed written statement by the President may vary the foregoing. However, employees in positions covered by a collective bargaining agreement are subject to the terms of such agreement. I understand any employment by the company will be on a 90-day probationary period. If employed, I will abide by its rules and regulations. I may be required to have a physical examination and/or a drug test as a precondition to hire.

BACKGROUND INVESTIGATION AUTHORIZATION *

I agree to the following: I hereby authorize the company and its designated agents and representatives to conduct a comprehensive review of my background causing an investigative consumer report to be generated for employment purposes and, in the event that I am offered employment, at any time during employment. I hereby grant permission to the company to contact present and previous employers and I further authorize my former employers to give any information as to my character and record, including employment dates, position, and salary (to the extent allowed by law). I release from all liability and responsibility all persons and entities requesting or supplying information about my employment experience listed on this application. I understand this information will be used in part to determine my eligibility for employment with the company. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: Verification of social security number; current and previous residences; employment history including all personnel files; education including transcripts; character references; criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; birth records; motor vehicle records to include traffic citations and registration; and any other public records or to conduct interviews with third parties relative to my character, employment history, and/or general reputation. I understand that upon written request to the company, I will be given information as to the nature and scope of the report or investigation, informed of the name and address of the consumer reporting agency furnishing the report, and provided with a Summary of Rights under the Fair Credit Reporting Act. I also understand that I will have an opportunity to review the criminal history as reported if I request in writing within 10 calendar days of notification of any problems or concern regarding information received.

Signature *

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Apply for Certified Occupational Therapy Assistant -COTA

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