Employment Application - Practitioner | Holistic Health Associates

Employment Application - Practitioner

Use the form below to inquire about employment opportunities with our company.

Personal
Full Name (First + Middle + Last)*
Drivers License Number*
Drivers License State*
Drivers License Copy*
Max. file size: 20 MB.
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Do you have the legal right to live and work in the U.S.?*
- Yes
- No
Other name(s) under which you have been previously employed
Names of friends or relatives employed in this organization
Have you ever applied to this organization before?*
- Yes
- No
If Yes, give date and position applied for
Have you ever been employed by this organization before?*
- Yes
- No
If yes, list dates of employment
Do you have any family, business, health, or social restrictions or obligations that would prevent you from performing the job responsibilities?*
- Yes
- No
Do you have any physical or mental condition or handicap which would endanger the health or safety of yourself and or others or that may affect your ability to perform the job(s) for which you are applying?*
- Yes
- No
If yes, please describe such condition or handicap.
Have you ever been convicted of a felony?*
- Yes
- No
If yes, list dates, offenses, and disposition.
Convictions are not an automatic disqualification from employment.
Will you comply with the safety work and attendance policies of our organization?*
- Yes
- No
Employment Interests
Position(s) Desired or Area of Interest:*
- Massage Therapist
- Acupuncturist
- Reiki Practitioner
- Other
Do you have a CAQH Profile?*
- Yes
- No
Please provide CAQH Profile ID
Date Available*
MM slash DD slash YYYY
Type of Employment You Are Seeking:*
- Part Time (15-30 hours)
- Full Time (30-40 hours)
Shifts You Can Work:*
- 9am - 5:30pm
- 10am - 6:30pm
- 12pm - 8:30pm
- Saturday
- Any
How will you get to work?*
How were you referred to our organization?*
- Advertisement
- Employee
- Other Company
- Agency
- Self
- Employment Service
Name of Referral Source:
In a few sentences please tell us what excited you about this opportunity and why do you want to work at Holistic Health Associates?
Education/U.S. Military Service

Where did you attend high school & college? (Click the + button to add a new row)*

School Name & Address	Major	Years Completed	GPA	Degree/Diploma

Are you taking any educational course(s) presently?*
- Yes
- No
- I will be soon
If Yes or you will be soon, what and where?
Have you ever served in the U.S. Armed Services?
- Yes
- No
US Military Duties and special training
Rank held at discharge
References

List 3-5 people we may contact who are qualified to evaluate your capabilities. Do not include relatives. (Click the + button to add a new row)

Name	Address	Occupation	Years Known	Phone Number

Employment History
Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.
Company Name (Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Dates Employed

From	To

Job Title
Supervisors Name & Title
Type of Business
Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Did you have another job before this one?*
- Yes
- No
Company Name (Second Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Dates Employed

From	To

Job Title
Supervisors Name & Title
Type of Business
Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list another previous job?
- Yes
- No
Company Name (Third Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Dates Employed

From	To

Job Title
Supervisors Name & Title
Type of Business
Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
Would you like to list a 4th job?
- Yes
- No
Company Name (Fourth Most Recent)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Dates Employed

From	To

Job Title
Supervisors Name & Title
Type of Business
Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties
Reason for Leaving?
May we contact this employer?
- Yes
- No
I agree to a Drug Screening at the company's expense.*
- Yes
- No
I agree to a Criminal Background Check at the company's expense.*
- Yes
- No
Acknowledgement
Insert Your Legal Terms of Service Here
Digital Signature:
Printing your First Name + Middle Initial + Last Name will act as your digital signature.
Date
MM slash DD slash YYYY
Resume Upload*
Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 20 MB.
Please attach your resume here.
Copy of State License*
Max. file size: 20 MB.
Malpractice Certificate*
Max. file size: 20 MB.
NPI #:
Would you like to add a cover letter?
- Yes
- No
Cover Letter (optional)
Max. file size: 20 MB.
Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.

Save and Continue Later

Employment Application - Practitioner

Personal

Employment Interests

Education/U.S. Military Service

References

Employment History

Acknowledgement