Artisan Rehabilitation Staffing, PC

Phone: (703) 933-0297

Fax: (703) 933-0697

E-mail: ArtisanRehabStaff@verizon.net

PERSONNEL APPLICATION & INFORMATION INTAKE FORM

Artisan Rehabilitation Staffing, P.C. is committed to providing and promoting equal employment opportunities for all applicants and employees. It is also the policy and practice of the company to hire, train, promote, compensate and administer all employment practices without regard to race, color, religion, sex, national, origin, age, marital status, medical condition, veteran status, sexual orientation or disability unrelated to the ability to perform the essential functions of the job. Furthermore, the company is committed to complying with the Americans with Disabilities Act. If you believe that you need a reasonable accommodation in order to complete an application for employment due to the fact that you have a disability, please notify the company within three (3) days of you application of you specific needs for a reasonable accommodation so that the company can assist you where appropriate. If an applicant requests an accommodation for purposes of completing the job application process, the company reserves the right to require the applicant to furnish documentation from an appropriate professional (ie. doctor, rehabilitation counselor, etc) confirming that the applicant has a disability or concerning their functional limitations for which a reasonable limitations accommodation is requested In order that your application my be properly evaluated, it is essential that all of the following questions be answered carefully and completely.

If you need more space for your answers, Please attach a separate sheet. Feel free to add any additional information which will help us with placing you where you are best qualified. Please print in ink or use a typewriter.

DATE: ___________

Name: _____________________________ Business name _____________________

Discipline: __________________________ (if clinical staff)

SS# or Tax ID # ________________________

Phone No:(H) __________________ (W)__________________ (cell)______________

Fax:_____________________ email address: ___________________________

Address:_____________________________________________________________

In case of emergency please notify:

__________________________________________________________________

Best Time/Place to reach you: ____________________________________________

Availability to work immediately: ____ Hours available:

__________________________

Days available:

_________________________________________________________

Languages other than English: ____________________________________________

Areas of Expertise (if clinical staff)_______________________________________

__________________________________________________________________

Other Info:

1. Have you ever had your therapy license revoked or suspended: Yes__ No__ NA__

If yes, please explain: Attach additional page if necessary.

__________________________________________________________________

__________________________________________________________________

2. Do you have the legal right to work and remain in the United States?

__________________________________________________________________

3. Have you ever been convicted of a felony, misdemeanor, or any offense other than a

minor traffic violation? Yes _________ No ________ . If yes, please explain

__________________________________________________________________

__________________________________________________________________

4. Have you ever committed an offense involving dishonesty or breach of trust or fraud?

Yes ___________ No ___________. If yes, explain

__________________________________________________________________

5. Is there any information relative to change of name necessary to enable _____ to

check references of prior employees?

__________________________________________________________________

__________________________________________________________________

6. Have you had any malpractice claims, suits or settlements in the last five years?

Yes___

No___ If yes, please explain:

__________________________________________________________________

__________________________________________________________________

7. To your knowledge are there any claims that have not been filed yet, but you have put

on notice about intent to file? Yes ______ No ________ If yes please explain

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

______

All information submitted in this application is warranted to be complete, correct and true. I authorize

______________________to consult with the _________State Board of Regents, the Office of the Inspector General, the

National Practitioners Data Bank, specialty boards, malpractice insurance carriers and any other person or entity from whom/which

information may be needed prior to gainful employment. I authorize all such entities to release such information to

______________________. I release ______________and its employees from any and all liability for their acts performed in

good faith and without malice in obtaining and verifying such information and in evaluating this application.

________________________________________ ___________________

Signature Date

Reviewed _____ Revised _____