Occupational Therapist Employment Application

This application will bring you one step closer to a career as a traveling OT. Please fill out the form below accurately and completely. Expect a quick response from one of our traveling occupational therapist specialists. Time is critical when looking for a traveling OT position so when you see an occupational travel position of interest please submit as soon as possible.

Personal Information
First Name:
Middle Name:
Last Name:
Street Address/ P.O. Box:
City:
State:
Zip:
Home Phone:
Cell Phone:
Fax:
Pager:
E-mail Address:
Emergency Contact Name:
Emergency Contact Phone:
Driver's License State:
Driver's License Number:

Driver's License Expires: (mm/dd/yyyy)
Are you legally authorized to work in the United States? Yes No
Who can we thank for your referral?
Have you ever applied to or been employed by Advanced Medical Personnel Services, Inc.? Yes No
Have you ever been convicted of any felony within the last 10 years? Yes No
Check As Appropriate:
(Certification)		 PT
PTA
OT
COTA
SLP
Type of Employment Desired: Travel (13-26 weeks)
Direct Placement
Fast Response (4 week only) Management

Professional Licensure/Certification
State:
License Number:
Expiration date: (mm/dd/yyyy)

Employment History
Clinical positions most recent first
1. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Telephone Number:
Your Title:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:

Employment History
2. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Telephone Number:
Your Title:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:

Employment History
3. Employed from:
 (mm/dd/yyyy)
Employed to:
 (mm/dd/yyyy)
Facility:
City:
State:
Zip:
Facility Supervisor's Name:
Facility Supervisor's Telephone Number:
Your Title:
Was this a travel assignment?
 Employee
Travel Assignment
Reason for Leaving:
Education Information

What is the highest clinical degree/certification received?
1. School Name, City & State:
Area of Concentration:
Year Graduated from School:

Degree Type:

2. School Name, City & State:
Area of Concentration:
Year Graduated from School:
Degree Type:

Assignment Preferences
Location:
Where do you want to go?
Describe your ideal position:
When are you available to start? (mm/dd/yyyy)
In selecting your next assignment, what is your most important consideration?
Upload Your Resume
Copy and Paste your resume below
4000 Character Limit (equivalent to 1 1/3 pages, 12 pt. type single spaced)


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