Employment Application Applicant DataFull Legal Name* First Middle Last Email Address* Enter Email Confirm Email Home Address* Street Address Unit / Suite Number City State Zip Code Have you lived at this address less than 5 years?* Yes NoPrevious Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Best Time To Call You*When is the best time for us to reach you via telephone?Best Time To Call YouMorningsEarly AfternoonLate AfternoonEarly EveningDate Available to Begin Work* Date Format: MM slash DD slash YYYY Hours You Are Available for Work*Please tell us what hours you are available for work each day of the week.MondayTuesdayWednesdayThursdayFridayAre you at least 18 years of age?* Yes NoDo you have the legal right to live and work in the US?*Proof of citizenship or immigration status are a requirement for employment Yes NoHave you ever been convicted of, plead guilty or 'no contest' to a felony?* No YesPlease describe:*Position Applying ForWhich position are you applying for?*Back Office SpecialistPatient Services SpecialistPhysical TherapistWhich state(s) are you licensed in?*Please list state(s) you are licensed in, your PT license number, and the expiration date.StateLicense #Expiration date Excluded from federally funded healthcare program?*Have you EVER been excluded from participation in any federally funded health care program, including but not limited to Medicare and Medicaid? No YesPlease describe:*Disciplinary action?*Has your physical therapy license ever been sanctioned or have you ever been disciplined by a licensing board in any state? No YesPlease describe:*EducationEducational Background*Beginning with High School, list the name(s) of colleges, universities, technical or trade-schools you've attended.Name of schoolDiploma or Degree EarnedCity, State Previous EmploymentAre you currently employed?* Yes NoMay we contact your present employer?* Yes NoPresent employer's name:* First Last Present employer's phone:*Your Previous Employers*Please list previous employers, the date range you work(ed), ending wage, and the position you hold/held. Include your three most recent jobs, and any other positions that are relevant to this job.EmployerDatesEnding WagePosition More About YouIntroduction*So that we can better get to know you and ensure you're a good fit for our company's culture, please briefly introduce yourself.Upload Your Resume*upload your resume in .pdf, .doc or .docx format Drop files here or Accepted file types: pdf, doc, docx.Legal StatementsCriminal Background Check*As participating providers in Medicare and other federal programs, all employees are required to undergo a criminal background check. If offered employment, I agree to participate in a criminal background checkTerms and ConditionsBy agreeing to our terms, I certify that all of the information contained in this application is true and complete. I understand that any misrepresentations or false information that I provide, either in this employment application or at any other time during the application and hiring process, may result in the disqualification of my application for employment or, if I am hired, in the immediate termination of employment at any point in the future.I understand and agree that this employment application does not guarantee employment on any terms. I further understand and agree that, if I am hired, it will be on a strictly at-will basis, meaning that just as I am free to resign at any time, Physical Therapy at Thrive, LLC has the right to terminate my employment at any time, with or without cause or prior notice. No implied oral or written agreements contrary to this at-will employment basis are valid unless they are in writing and signed by the President of Physical Therapy at Thrive, LLC.I understand that Physical Therapy at Thrive, LLC may seek to verify any or all information listed above or otherwise provided by me during the application and hiring process. I hereby expressly authorize Physical Therapy at Thrive, LLC to verify that information, without further notice to or consent by me, and I authorize prior employers and others from whom such verification is sought to release relevant information about me. I further authorize Physical Therapy at Thrive, LLC to investigate all references and secure additional information about me.I hereby release from liability Physical Therapy at Thrive, LLC and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.Physical Therapy at Thrive, LLC is an Equal Opportunity Employer. Physical Therapy at Thrive, LLC does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.Acceptance* I agree to the Terms and ConditionsI'm not a robotCommentsThis field is for validation purposes and should be left unchanged.