Application for Music Therapist

Applicant Full Name:*

Applicant Email Address*

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mobile Phone Number:*

Social Security Number:*

Driver's License (State/Number):*

Who referred you to our company?*

Are you at least 18 years old?*

Yes
No

How will you get to work?*

Are you willing to work any shift, including nights and weekends?*

Yes
No

If no, please state any limitations:*

If you are offered employment, when would you be available to begin work?*

If hired, are you able to submit proof that you are legally eligible for employment in the United States?*

Yes
No

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?*

Yes
No

What reasonable accommodation, if any, would you request?*

Have you ever been convicted of a felony or misdemeanor?*

Yes
No

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.

Conviction:*

Date of conviction:*

City of Conviction:*

State of Conviction:*

List current or most recent employer:*

List all jobs (including self-employment and military service) which you have held, beginning with the most recent.

Supervisor's name:*

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job duties:*

Reason for Leaving:*

Dates of Employment (Month/Year):*

List previous employer:*

Supervisor's name:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job duties:*

Reason for Leaving:*

Dates of Employment (Month/Year):*

Name of College/University Attended:*

Address of College/University Attended:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Have you graduated?*

Yes
No

Degree received:

Date of graduation:*

Other Training (graduate, technical, vocational):*

Please indicate any current professional licenses or certificates that you hold:*

Awards, Honors, Special Achievements:*

Military Service?*

Yes
No

Branch:*

Specialized Training:*

Reference #1*

List 2 non-relatives who would be willing to provide a reference for you.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Telephone:*

Relationship:*

Reference #2*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Telephone:*

Relationship:*

Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer:*

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Music Therapist Application