The Therapy Network – Employment Application 1. Personal Information Full Name* Preferred Name (optional) Phone Number* Email Address* Current Address* City, State, ZIP* Best time to contact (optional) Preferred contact method (optional) PhoneEmailOther Are you legally authorized to work in the United States?* YesNo Will you now or in the future require visa sponsorship?* YesNo 2. Position Information Position You Are Applying For* Location Preference* ChesapeakeFirst ColonialGhent at Hague Medical CenterKempsvilleNewtownNo preference Desired Employment Type* Full-timePart-timePRN Available Start Date* Desired Salary or Hourly Rate (optional) Current or Most Recent Employer (optional) Job Title Dates Employed 3. Education Highest Level of Education Completed* High SchoolAssociate’sBachelor’sMaster’sDoctorateOther Institution(s) Name & Program of Study Graduation Year(s) 4. Licenses Do you currently hold any professional licenses applicable to this position?* YesNo If yes, please list all professional licenses: License Type License Number State of Issuance Expiration Date 5. Certifications Do you currently hold any professional certifications relevant to this position?* YesNo If yes, please list all relevant certifications: Certification Name Issuing Organization Expiration Date 6. Skills & Qualifications Briefly describe any clinical, administrative, technical, or interpersonal skills relevant to this role: Do you have experience with an electronic medical record (EMR)?* YesNo If yes, please specify which EMR(s): Languages spoken (optional) 7. Professional References Please provide two professional references (supervisors or colleagues, not family). Reference #1 Full Name Relationship Organization Phone Email Reference #2 Full Name Relationship Organization Phone Email 8. Availability & Scheduling Clinic hours vary by location and can fall anywhere between 6:00 AM and 7:00 PM Monday through Friday. Use the checkboxes below to indicate the general times of day you are available to work. What days of the week are you available to work? MondayTuesdayWednesdayThursdayFriday What times of day are you available to work? MorningDayEvening Do you have transportation that allows you to reliably travel to and between our clinic locations if needed?* YesNo Are there any restrictions or limitations on your availability we should know about? (optional) 9. Additional Information Why do you want to work at The Therapy Network? How did you hear about this position? TTN websiteSocial mediaReferralCurrent employeeIndeedOther If referral/employee/other, please specify: 10. Resume & Cover Letter Upload Resume (PDF, DOC, DOCX)* Upload Cover Letter (optional) 11. Applicant Certification & Signature By submitting this application, I certify that the information provided is true and complete to the best of my knowledge. I understand that any false or misleading information may result in disqualification from employment or termination if hired. Digital Signature* Date*
