If selected "Other" for Credential, please explain:
Professional License Number (000.000000):
If selected "Other" for Credential, please put "N/A" for License Number above.
select oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Phone Number (000-000-0000): *required*
What is the best time to call you?
Date available to start working (MM/DD/YYYY):
Current Rate ($XX.XX/hour):
select oneTherapist StaffTherapy Tech StaffOffice StaffOther
If selected "Other" for Desired Position, please explain:
select oneFull TimePart TimePRN
Which days are you available?
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
If "Desired Status" is PRN, how many hours are you available each week?
Are you a citizen of the United States?
Are you authorized to work in the United States?
Have you ever worked for Quality Therapy?
If yes, when?
Have you ever been convicted of a misdemeanor?
If yes, please explain:
Have you ever been convicted of a felony?
How did you hear about Quality Therapy?
select oneColleague/FriendFormer StudentQuality Therapy's WebsiteIndeed.comCraigslistReceived a FlyerReceived a Phone CallAttended one of our CoursesOther
If selected "Colleague/Friend", please list their name below:
If selected "Other", please describe below:
References - Please list two professional references.
Reference 1 - Full Name:
Reference 1 - Relationship Type:
Reference 1 - Company:
Reference 1 - Phone:
Reference 2 - Full Name:
Reference 2 - Relationship Type:
Reference 2 - Company:
Reference 2 - Phone:
Upload Resume: (.PDF, .doc, .docx, .txt, .jpg)
You may leave the “Education” and/or “Previous Employment” section(s) blank if that information appears on the resume you upload with this application.
Did you graduate?
Company Phone Number:
Starting Rate ($XX.XX/hour):
Ending Rate ($XX.XX/hour):
Reason For Leaving:
May we contact your supervisor?
May we contact your previous supervisor?
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
I certify that and accept the above statement:
Prove you are human:
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