APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

FULL NAME: ___________________________________ DATE: __________________

                          First                       Middle                              Last       

ADDRESS: _____________________________________________________________

Street Address                                                                                                  Apt/Suite         

_____________________________________________________________

City                                                     State                                                      Zip Code        

E-MAIL: __________________________________ PHONE: _____________________

SOCIAL SECURITY NUMBER (SSN): _____-____-_____   

DATE AVAILABLE: __________________ DESIRED PAY: $_________ ☐ HOUR  ☐ SALARY

POSITION APPLIED FOR: _________________________________________________

EMPLOYMENT DESIRED: ☐ FULL-TIME  ☐ PART-TIME  ☐ SEASONAL

EMPLOYMENT ELIGIBILITY

ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES  ☐ NO*                                                                        

ARE YOU 16 YEARS OLD OR OLDER? ☐ YES  ☐ NO*                                                                        

HAVE YOU EVER WORKED FOR THIS EMPLOYER BEFORE? ☐ YES*  ☐ NO

*IF YES, WRITE THE START AND END DATES: ____________________________________

HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES*  ☐ NO

*IF YES, PLEASE EXPLAIN: ____________________________________________________

EDUCATION

HIGH SCHOOL: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________ 

GRADUATE? ☐ YES  ☐ NO DIPLOMA: _____________________

COLLEGE: _____________________ CITY / STATE: _____________________

FROM: _____________________ TO: _____________________ 

GRADUATE? ☐ YES  ☐ NO DEGREE: _____________________

OTHER TRAINING OR CERTIFICATIONS: ___________________________________

CITY / STATE: _________________________    DATE: _________________________

OTHER TRAINING OR CERTIFICATIONS: ___________________________________

CITY / STATE: _________________________    DATE: _________________________

PREVIOUS EMPLOYMENT 

EMPLOYER 1: __________________________________________________________

Company / Individual

E-MAIL: __________________________________ PHONE: _____________________

STARTING PAY: $_________ ☐ HOUR  ☐ SALARY ENDING PAY: $________ ☐ HOUR ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

EMPLOYER 2: __________________________________________________________

Company / Individual

E-MAIL: __________________________________ PHONE: _____________________

STARTING PAY: $_________ ☐ HOUR  ☐ SALARY ENDING PAY: $_______ ☐ HOUR  ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

EMPLOYER 3: __________________________________________________________

Company / Individual

E-MAIL: __________________________________ PHONE: _____________________

STARTING PAY: $_________ ☐ HOUR  ☐ SALARY ENDING PAY: $_______ ☐ HOUR  ☐ SALARY

JOB TITLE: ______________ RESPONSIBILITIES: _____________________________

FROM: _____________________ TO: _____________________

REASON FOR LEAVING: _______________________________________________________

REFERENCES

(PROFESSIONAL ONLY)                       

FULL NAME: _______________________________ RELATIONSHIP: ______________

First                                               Last       

COMPANY: ________________________________ TITLE: ______________

E-MAIL: __________________________________ PHONE: _____________________

FULL NAME: _______________________________ RELATIONSHIP: ______________

First                                               Last       

COMPANY: ________________________________ TITLE: ______________

E-MAIL: __________________________________ PHONE: _____________________

MILITARY SERVICE 

ARE YOU A VETERAN? ☐ YES  ☐ NO

BRANCH: _____________________ RANK AT DISCHARGE: _____________________

FROM: _____________________ TO: _____________________ 

TYPE OF DISCHARGE: _____________________

IF NOT HONORABLE, PLEASE EXPLAIN: ______________________________________

BACKGROUND CHECK CONSENT 

IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? ☐ YES  ☐ NO

DISCLAIMER 

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered. 

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

SIGNATURE _________________________________ DATE _____________________

PRINT NAME _________________________________

Please fill out and email to clinic@gracetherapy.com