Employment at RI Rehabilitation - Physical and Occupational Therapy Specialists

Application For Employment

(Pre-Employment Questionnaire) (An Equal Opportunity Employer)

Personal Information:

First Name:	Last Name:	Social Security Number:
Street Address:
City:	State:	Zip Code:
Phone Number:	Are you 18 years or older? Yes No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status? Yes No

Employment Desired:

Position:	Date you can start:	Salary Desired:
Are you currently employed? Yes No	If yes, who is your present employer? (optional)
Have you applied to RI Rehab before? Yes No	Where?	When?
Referred By:

Education

High School

Name of School:

Location of School:

Year Graduated:

College

Name of School:	Location of School:	Year Graduated:
Degree Obtained:	Major:

Graduate School

Name of School:	Location of School:	Year Graduated:
Degree Obtained:	Major:

Please Answer the Following Questions:

Have you ever been on probation or sentenced to jail/prison as a result of a felony conviction or quilty plea to a felony charge? Yes No
If "Yes," please provide the following information:
Law Enforcement Authority (city police, sheriff, FBI, etc.):	Offense:	Date of Offense:
Place and Disposition of Case:
Have you ever been fired from a job or resigned to avoid dismissal? If "Yes," please explain. A "Yes" answer will not necessarily bar you from state employment.
Yes No

Former Employers (List below your last three employers, starting with the most recent one first.)

References (Give the names of three persons not related to you, whom you have known at least one year.)

Name:	Address:
Business:	Years Aquainted:	Phone Number:

Name:	Address:
Business:	Years Aquainted:	Phone Number:

Name:	Address:
Business:	Years Aquainted:	Phone Number: