Dominion Physical Therapy

Please see our addresses below to find a location near you.

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JOB APPLICATION

Dominion Physical Therapy & Associates

729 Thimble Shoals Blvd. Suite 4C, Newport News, Virginia 23606

Dominion Physical Therapy & Associates is an equal opportunity employer. This application will not be used for limiting or excluding any application from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all the sections below:

Applicant Name

Address

City, State and Zip Code

Telephone Number

Email Address

Date of Application

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Employment Position

How did you hear about this position?

What days are you available for work?

What hours of shift are you available for work?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Salary Desired

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Employment Position

Have you ever applied to or worked for Dominion Physical Therapy & Associates before?

Yes

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Do you have any friends, relatives, or acquaintances working for Dominion Physical Therapy & Associates?

If yes, state name & relationship

Are you 18 years of age or older?

Are you a U.S Citizen or approved to work in the United States?

What document can you provide as proof of citizenship or legal status?

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case

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(Note: No applicant will be denied employment solely on grounds of conviction of a criminal offense. The data of the offense, the nature of the offense, including any significant details that affect the description of the event. and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Please list below the skills and qualifications you possess foe the position for which you are applying

New Field:

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Note: Dominion Physical Therapy & Associates complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

Education and Training

High School

Name

Location (City, State)

Year Graduated

Degree Earned

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College/University

Name

Location (City, State)

Year Graduated

Degree Earned

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Vocational School/ Specialized Training

Name

Location (City, State)

Degree Earned

Year Graduated

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Military:

Are you a member of the Armed Services?

What branch of the military did you enlist?

What was your military rank when discharged?

How many years did you serve in the military?

What military skills do you possess that would be an asset for this position?

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Previous Emplyment

Employer Name

Job Title

Supervisor Name

Employer Address

City, Sate, and Zip Code

Employer Telephone

Dates Employed

Reason for Leaving

Employer Name

Job Title

Supervisor Name

Employer Address

City, Sate, and Zip Code

Employer Telephone

Dates Employed

Reason for Leaving

Employer Name

Job Title

Supervisor Name

City, Sate, and Zip Code

Employer Telephone

Reason for Leaving

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References: Please provide 3 personal and professional reference(s) below:

References 1

Contact Information

References 2

Contact Information

References 3

Contact Information

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AT-WILL EMPLOYMENT

The relationship between you and the Dominion Physical therapy & Associates (DPT) is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the DPT. No representative of DPT has authority to enter into any agreement contrary to the foregong "employment at will relationship. You understand that your employment can alter your at will employment status, except for a written statement signed by you and either our Executive Vise-President/Chief Operations Officer or the Company's President.

Applicant Signiture

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Date

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Text DOMINIONPT to 85100 for Updates and Key Information.

Dominion Physical Therapy

304 Marcella Rd., Suite E

Hampton, VA 23666

Ph: (757) 825-9446

Fax: (757) 825-9476

Dominion Physical Therapy

901 Hampton Blvd Ste 302

Norfolk, VA 23510

Ph: (757) 963-5588

Fax: (757) 963-2333

Dominion Physical Therapy

729 Thimble Shoals Blvd., Suite 4C

Newport News, VA 23606

Ph: (757) 873-2932

Fax: (757) 873-8780

All offices of Dominion Physical Therapy are open from 9am to 6pm Monday through Friday. Individual patient needs are accommodated by appointments both earlier and later than normal office hours.