Quality Therapy & Consultation, Inc.
(708) 326-1550
 
Please send employment inquires and resumes to the Recruiting Department at Recruiting@qtctherapy.com.

Employment Application Form

First Name:

Last Name:

Credentials:

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.

Address:

City:

State:

Zip Code:

Email Address:

Phone Number (000-000-0000):

What is the best time to call you?

Date available to start working (MM/DD/YYYY):

Current Rate ($XX.XX/hour):

Desired Position:

If selected "Other" for Desired Position, please explain:

Desired Status:

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?
Yes No 

Are you authorized to work in the United States?
Yes No 

Have you ever worked for Quality Therapy?
Yes No 

If yes, when?

Have you ever been convicted of a misdemeanor?
Yes No 

If yes, please explain:

Have you ever been convicted of a felony?
Yes No 

If yes, please explain:

How did you hear about Quality Therapy?

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.


Education

College Name:

College Address:

Date Attended:

From (MM/YYYY)

To (MM/YYYY)

Did you graduate?
Yes No 

Degree:

 

College Name:

College Address:

Date Attended:

From (MM/YYYY)

To (MM/YYYY)

Did you graduate?
Yes No 

Degree:


Previous Employment

Company Name:

Company Phone Number:

Company Address:

Supervisor:

Job Title:

Starting Rate ($XX.XX/hour):

Ending Rate ($XX.XX/hour):

Responsibilities:

From (MM/YYYY):

To (MM/YYYY):

Reason For Leaving:

May we contact your supervisor?

 

Company Name:

Company Phone Number:

Company Address:

Supervisor:

Job Title:

Starting Rate ($XX.XX/hour):

Ending Rate ($XX.XX/hour):

Responsibilities:

From (MM/YYYY):

To (MM/YYYY):

Reason For Leaving:

May we contact your previous supervisor?

Additional Comments:


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:
Yes No 

Date (MM/DD/YYYY):

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