SECURE RELIEF, INC.
  201 Compo Road South       
Westport Ct. 06880
Tel: 203 226 6793
Fax: 203 226 1516
                                                 


PHYSICAL THERAPIST APPLICATION
AMERICAN CITIZEN
 
 
 
Name:                                                S.S. #                                    D.O.B.
Address:                                            City, State:                              Zip: 
Phone #  Business:                              Fax:                                       Home:
 
Licensed__________________         License #s________________________
                    States
Malpractice Insurance:  Y  N     Company_____________      Insured Amount______
 
BACKGROUND INQUIRY:  If you answer yes to any of the following questions
please provide a detailed explanation on a separate sheet.
 
1] Have you ever surrendered or had your state license refused, restricted, suspended
or revoked?  YES  NO
 
2] Has any action[s] ever been taken against you by the licensing board of any state?
    YES  NO
 
3]  Have you ever been reprimanded or had your membership refused, suspended, or
revoked by any professional organization?  YES  NO
 
4] Have you ever been named as a party in a malpractice suit?  YES  NO
 
5] Have you ever been convicted of a crime other than a minor traffic offense?
    YES  NO
 
6] Have you ever been treated for alcoholism or narcotic addiction?  YES  NO
 
7] Do you have any physical, mental, or addictive problems that may interfere with
carrying out your professional responsibilities?   YES  NO
 
8] Have you ever been the subject of  investigation by any peer review committee?
 
9] List memberships in national, state, and local professional organizations.
 
 
 
 
 


PROFESSIONAL PROFILE:
 

Graduated from_____________________ physical therapy college.  YR:
 

Practice experience:  # of years:     # of months:
 

Certification[s] and post-doctoral education
 

Daily volume able to handle:    
 

 Travel restrictions:   30mi.                                50mi.                           None:
 

Family structure: [married, single, children, please circle]
 

Willing to relocate?
 

How much time do you need before you can begin work?
 

Please add any additional information that makes you special or unique.  [for instance
bilingualism]
 
 
 
Signature:____________________________Date:_________________________
 

THANK YOU FOR YOUR TIME AND ATTENTION.  WE LOOK FORWARD TO
DOING BUSINESS WITH YOU!
 
© 2004 Secure Relief Inc.