If under the age of 18, can you produce the necessary work certificate at the time of employment?
YesNo
Type of employment desired?
Full-timePart-time (Specify Hours)
Are you willing to work overtime?
YesNo
Have you previously applied for employment with this Company?
YesNo
Have you ever been employed by this Company?
YesNo
Education:
High School
Graduate? YesNo
College
Graduate? YesNo
Bus./Tech./Trade or Post College
Graduate? YesNo

WORK EXPERIENCE

Please list the names of your present and/or previous employers in chronological order with present or most recent employer listed first. Provide information for at least the most recent ten (10) year period. Attach additional sheets if needed. If self-employed, supply firm name and business references.You may include any verifiable work performed ona volunteer basis, internships, or military service. Your failure to completely respond to ech inquiry may disqualify you for consideration from employment. Do not answer “see résumé.”

Employer

Dates Employed:
May we contact?YesNo

Employer

Dates Employed:
May we contact?YesNo
Have you ever been terminated or asked to resign from any job:
YesNo
Has your employment ever been terminated by mutual agreement?
YesNo
Have you ever been given the choice to resign rather than be terminated?
YesNo

REFERENCES

Please list the names of additional work-related references we may contact. Individuals with no prior work experience may list school or volunteer-related references.

NAME

POSITION

COMPANY

WORK RELATIONSHIP
(i.e., supervisor, coworker)

TELEPHONE

Please list the names of personal references (not previous employers or relatives) who know you well that we may contact.
NAME

OCCUPATION

ADDRESS

TELEPHONE

NUMBER OF
YEARS KNOWN

DRIVING INFORMATION [Optional]

(Complete only if driving is an essential function of the job for which you are applying).

Do you have a current valid driver’s license?
YesNo
Has your license ever been suspended or revoked?
YesNo
Do you have personal automobile insurance?
YesNo
Have you ever been denied personal automobile insurance or has it ever been terminated or suspended?
YesNo
Please list all moving traffic violations in the last five (5) years:
OFFENSE

DATE

LOCATION

COMMENTS

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment iscontingent on possessing a valid driver's license for the state in which I reside and automobile liability insurance in an amount equal to theminimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent withapplicable federal, state, and local law. If the Company has such a program and I am offered a conditional offer of employment, I understandthat if a pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under theconditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees of thelocation, pursuant to the Company's policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or othermedically recognized tests designed to detect the presence of alcohol or illegal or controlled drugs. If employed, I understand that the taking ofalcohol and/or drug tests is a condition of continual employment and I agree to undergo alcohol and drug testing consistent with the Company's policies and applicable federal, state, and local law.

I understand and agree that as a condition of employment and to the extent permitted by federal, state, and local law, I may be required to signa confidentiality, restrictive covenant, and/or conflict of interest statement.

I certify that all the information on this application, my résumé, or any supporting documents I may present during any interview is and will becomplete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of any information mayresult in disqualification from consideration for employment or, if employed, disciplinary action, up to and including immediate dismissal.

I authorize and consent to, without reservation, any party or agency contacted by this employer to furnish the above-mentioned information. Ihereby release, discharge, and hold harmless, to the extent permitted by federal, state, and local law, any party delivering information to theCompany or its duly authorized representative pursuant to this authorization from any liability, claims, charges, or causes of action which I mayhave as a result of the delivery or disclosure of the above requested information. I hereby release from liability the Company and itsrepresentative for seeking such information and all other persons, corporations, or organizations furnishing such information. Further, if hired, Iauthorize the company to provide truthful information concerning my employment to future employers and hold the company harmless forproviding such information.

If hired by this Company, I understand that I will be required to provide genuine documentation establishing my identity and eligibility to belegally employed in the United States by this Company. I also understand this Company employs only individuals who are legally eligible to workin the United States.

THIS COMPANY IS AN AT-WILL EMPLOYER AS ALLOWED BY APPLICABLE STATE LAW. THIS MEANS THAT REGARDLESS OF ANYPROVISION IN THIS APPLICATION, IF HIRED, THE COMPANY OR I MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANYTIME, FOR ANY REASON, WITH OR WITHOUT CAUSE OR NOTICE. NOTHING IN THIS APPLICATION OR IN ANY DOCUMENT ORSTATEMENT, WRITTEN OR ORAL, SHALL LIMIT THE RIGHT TO TERMINATE EMPLOYMENT AT-WILL. NO OFFICER, EMPLOYEE ORREPRESENTATIVE OF THE COMPANY IS AUTHORIZED TO ENTER INTO AN AGREEMENT—EXPRESS OR IMPLIED—WITH ME OR ANYAPPLICANT FOR EMPLOYMENT FOR A SPECIFIED PERIOD OF TIME UNLESS SUCH AN AGREEMENT IS IN A WRITTEN CONTRACTSIGNED BY THE PRESIDENT OF THE COMPANY.IF HIRED, I AGREE TO CONFORM TO THE RULES AND REGULATIONS OF THECOMPANY, AND I UNDERSTAND THAT THE COMPANY HAS COMPLETE DISCRETION TO MODIFY SUCH RULES AND REGULATIONSAT ANY TIME, EXCEPT THAT IT WILL NOT MODIFY ITS POLICY OF EMPLOYMENT AT-WILL.

I authorize the Company or its agents to confirm all statements contained in this application and/or résumé as it relates to the position I amseeking to the extent permitted by federal, state, or local law. I agree to complete any requisite authorization forms for the backgroundinvestigation which may be permitted by federal, state and/or local law. If applicable and allowed by law, I will receive separate writtennotification regarding the Company's intent to obtain "consumer reports."

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF SIXTY (60) DAYS. IF YOU WISH TO BE CONSIDERED FOREMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I CERTIFY THAT ALL OF THE INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

DO NOT SIGN UNTIL YOU HAVE READ OF OF THE INFORMATION CONTAINED IN THE APPLICATION.

If the applicant is a minor, the foregoing release and consent must be signed by the applicant's parent or legal guardian. Signature by the applicant's parent or legal guardian constitutes acknowledgement by the applicant and the parent or legal guardian that the Company, to the extent permitted by federal, state, and local law, can test the applicant for illegal or controlled substances, conduct inspections of property without notice, and communicate test results to Company personnel who need to know, the applicant, and the applicant's legal guardian.

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR, POLYGRAPH, OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. I have read and understand the above statement.

IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.

FOR CALIFORNIA APPLICANTS ONLY: BY CHECKING THIS BOX, I WAIVE MY RIGHT TO RECEIVE A COPY OF ANY PUBLIC RECORD OBTAINED BY THE COMPANY FOR EMPLOYMENT PURPOSES THROUGH AN INTERNAL INVESTIGATION.

FEDERAL AND/OR STATE LAW MAY PROHIBIT THE USE OF LIE DETECTOR, POLYGRAPH OR SIMILAR TEST AS WELL.

THIS APPLICATION MAY NOT BE SUFFICIENT FOR ALL INDUSTRIES OR APPROPRIATE FOR USE IN ALL LOCALITIES.

*This employment application not appropriate for use by Rhode Island employers exempt from the state’s Workers’ Compensation laws.

If you are having issues submitting the application you can print and email to hrjobs@fherehab.com or fax to 954-246-5680