Full-Time Certified Occupational Therapy Assistant (COTA)

Personal Information

Last Name*

First*

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Permanent (or mailing) Address*

Street Address City State ZIP Code

Are you currently living at this address?*

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For instance, you may be away at college or currently deployed in the Armed Forces

Present Address

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Personal Phone Number*

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Email Address

Prior Names

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Are you legally authorized to work in the United States?*

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Have you lived in the State of Ohio for the past 5 years?*

Yes

No

Are you age 18 or older?*

Yes

No

Have you ever been convicted of a crime?*

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No

If yes, please give details.

General Job Information

Position Desired

Referred by

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Referral detail

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Type of Work Desired

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Shift Desired

Shift

Salary Desired

Salary

Type of Work Desired

Second Choice

Shift Desired

Shift

Salary Desired

Salary

Type of Work Desired

Third Choice

Shift Desired

Shift

Salary Desired

Salary

Availability*

Full-time

Part-time

Regular Basis

Temporary Basis

Have you ever applied for work here before?

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No

When?

Have you ever been employed here before?

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When?

Employment History

Beginning with your most recent employer, please list your last three employers.

Most Recent Employer

Name of Employer #1

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Position

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Brief Description of Duties

Employer #2

Name of Employer #2

Type of Business

Address

Street Address City State ZIP Code

Position

Salary

Dates Employed

From

To

Reason for Leaving

Name of Supervisor

Brief Description of Duties

Employer #3

Name of Employer #3

Type of Business

Address

Street Address City State ZIP Code

Position

Salary

Dates Employed

From

To

Reason for Leaving

Name of Supervisor

Brief Description of Duties

Personal References

Please do not list family members

First Reference

Name

Address

Phone

Occupation

Second Reference

Name

Address

Phone

Occupation

Third Reference

Name

Address

Phone

Occupation

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Email*

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Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge, and understand and agree that any misrepresentation or omission on my application or related papers, or made during any oral interviews may result in refusal of employment or shall be considered grounds for dismissal.

St. Augustine Health Ministries may make an investigation of my history and may verify all data given in my application of employment, and that if hired, my employment is at will, for no definite period, and my be terminated at any time without prior notices, without liability for wages, salary or any benefits except those earned up to the date of termination. If employed by St. Augustine Health Ministries, I agree to undergo medical examinations, including drug and alcohol testing, at any time at the option of St. Augustine Health Ministries, and I also understand and agree that i will abide by its rules and regulations.

If separated from employment from St. Augustine Health Ministries for any reason, I authorize it to furnish any information to employment references and release from liability it and/or any person giving or receiving any such information.

Acknowledgement of Applicant's Statement*

I have read, understand, and agree to the above.

Full-Time Certified Occupational Therapy Assistant (COTA)

Personal Information

General Job Information

Employment History

Most Recent Employer

Employer #2

Employer #3

Personal References

First Reference

Second Reference

Third Reference

Education

Professional License and/or Certificates

Military Service

Availability Record

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Applicant's Statement

Health Campus

Holy Family

St Augustine