Employment Application

• Your name ( Last First MI )
  
• Address ( Street, City, State & Zip Code )
  
• Home Phone #
  
• Business Phone #
  
• Other Phone #
  
• Email Address
  
• Date Available to Start
  
• Desired Position
  
• Regular
• Part-Time
• Temporary
• Have you ever applied for a position with CTC
  YesNo
• If yes when
  
• Have you ever been employed by CTC
  YesNo
• If yes when
  
• How did you learn about CTC
  
• How did you become aware of the open position with CTC
  
• If referred please provide employees full name
  

Education Information

• High School

• Name of School, City, and State
  
• Graduated/GED
  YesNo
• Major Course of Study
  

• College

• Name of School City State
  
• Years Completed
  
• Major Course of Study
  

• Graduate School

• Name of School, City, and State
  
• Years Completed
  
• Major Course of Study
  

• Trade Business Night or Correspondence

• Name of School, City, and State
  
• Years Completed
  
• Major Course of Study
  

• Other

• Name of School, City, and State
  
• Years Completed
  
• Major Course of Study
  

Employment History

Employer 1

• Name
  
• Address
  
• Address Line 2
  
• City
  
• State
  
• Zip
  
• Title
  
• Duties
  
• From
  
• To
  
• Salary
  
• per
  
• Type of Business
  
• Supervisor
  
• Phone
  
• Reason for leaving
  

Employer 2

• Name
  
• Address
  
• Address Line 2
  
• City
  
• State
  
• Zip
  
• Title
  
• Duties
  
• From
  
• To
  
• Salary
  
• per
  
• Type of Business
  
• Supervisor
  
• Phone
  
• Reason for leaving
  

Employer 3

• Name
  
• Address
  
• Address Line 2
  
• City
  
• State
  
• Zip
  
• Title
  
• Duties
  
• From
  
• To
  
• Salary
  
• per
  
• Type of Business
  
• Supervisor
  
• Phone
  
• Reason for leaving
  

Employer 4

• Name
  
• Address
  
• Address Line 2
  
• City
  
• State
  
• Zip
  
• Title
  
• Duties
  
• From
  
• To
  
• Salary
  
• per
  
• Type of Business
  
• Supervisor
  
• Phone
  
• Reason for leaving
  

• ---

• Please explain any gaps in employment history
  

References

• List the name and phone number of three work references who are not related to you. At least two should be former supervisors. If you have not had two supervisors, list school or personal references that are not related to you.

Reference 1

• Name
  
• Relationship to You
  
• Title & Company
  
• Telephone
  
• of Years Known
  

Reference 2

• Name
  
• Relationship to You
  
• Title & Company
  
• Telephone
  
• of Years Known
  

Reference 3

• Name
  
• Relationship to You
  
• Title & Company
  
• Telephone
  
• of Years Known
  

Additional Employment History Information

• May we contact your present Employer?
  YesNo
• Previous Employers?
  YesNo
• Please indicate reasons for not contacting them:
  
• In order to permit a check of your work and education records, have you ever been known by another name? (An affirmative response will not automatically disqualify you from being considered for employment)
  YesNo
• If “yes”, identify name(s) and relevant dates.
  
• Have you ever been dismissed or forced to resign from any employment? (An affirmative response will not automatically disqualify you from being considered for employment)
  YesNo
• If “yes” please explain
  
• If employment is offered, can you produce verification of your legal right to employment in the USA?(Birth Certificate, SS Card, or Certificate of US Citizenship?)
  YesNo
• If under the age of 18, please give Date of Birth:
  
• Please review the Job Description for the position you seek. Are you able, with or without accommodation, to perform essential responsibilities and duties described for the position?
  YesNo
• (Answering “yes” to this question will not automatically disqualify you from being considered for employment). If accommodation is needed, you are invited, but not required, to help us comply with our obligations under the Americans with Disabilities Act by describing what you think should be done to accommodate you.
  

Other Special Skills

• Describe any other special job-related skills or qualifications (e.g., Military experience, Professional Associations, etc.), you feel would be valuable to the position for which you are applying.
  
• Do you now hold, or have your ever held, a license or certificate to practice any profession in any jurisdiction?
  YesNo

• If “yes”, please list each license/certificate, state or jurisdiction and provide appropriate information in the columns below.

• License/Certificate 1

• Professional Title
  
• State of Jurisdiction
  
• Date License/Certificate Issued
  
• License/Certificate Number
  
• Limitations on License/Certificate
  

• License/Certificate 2

• Professional Title
  
• State of Jurisdiction
  
• Date License/Certificate Issued
  
• License/Certificate Number
  
• Limitations on License/Certificate
  

• License/Certificate 3

• Professional Title
  
• State of Jurisdiction
  
• Date License/Certificate Issued
  
• License/Certificate Number
  
• Limitations on License/Certificate
  

• License/Certificate 4

• Professional Title
  
• State of Jurisdiction
  
• Date License/Certificate Issued
  
• License/Certificate Number
  
• Limitations on License/Certificate
  

• ---

• Do you currently have a CAQH Provider I.D.?
  YesNo
• If “yes”, please provide your identification number
  
• Do you currently have a NPI#?
  YesNo
• If “yes”, please provide your identification number
  

• ---

Are You Certified in the Following?

• Cardio Pulmonary Resuscitation (CRP)
  YesNo
• Healthcare
  YesNo
• First Aid
  YesNo
• Pediatric Advanced Life Support
  YesNo
• Basic Life Support (BLS)
  YesNo
• Advanced Trauma Life Support (ATLS)
  YesNo
• Advanced Life Support OB (ALSO)
  YesNo
• Neonatal Advanced Life Support (NALS)
  YesNo
• Advanced Cardiac Life Support (ACLS)
  YesNo
• Neonatal Resuscitation Program (NRP)
  YesNo

• I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Connections Therapy Center to verify their accuracy and to obtain reference information on my work performance. I hereby release Connections Therapy Center from any and all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information.

• I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.

• I understand that should an employment offer be extended to me and accepted that I will fully adhere to policies, rules and regulations of employment of Connections Therapy Center. I understand that any employment offered is for an indefinite duration and at will and that either I or Connections Therapy Center may terminate my employment at any time with or without notice or cause.

• Signature
  
• Date
  

• Please upload your cover letter and resume:

• Resume
  
• Coverletter