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


PHYSICAL THERAPIST APPLICATION
FOREIGN NATIONAL
(note address at bottom to send to)
 
 
 
Name:                                              
S.S. #  [if you have one]                                 
Date of birth:
Address:                                            
City, State:  
Zip: 
Country 
Gender
Family structure: [married, single, children, please circle]
Phone[s]     Business:                   Cell:                     Fax:                             Home:
 
Licensed__________________         License #s________________________
                    States, Country
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?
 
 
PROFESSIONAL PROFILE:
 

Graduated from_____________________ physical therapy college.  YR:
Graduated from_____________________ high school.  YR:
Have you passed English  tests to meet American standards?
 

Practice experience:  # of years:     # of months:
Please attach CV to this application.
 

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?
 

List memberships in national, state, and local professional organizations.
 




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

IMMIGRATION STATUS
 
Passport#:
 

Visa type?
 

Have you ever applied or been issued an H1-B Visa or green card?   If yes, which and
when?
 

Do you need sponsorship?
 

How long have you been in the USA?
 


Please Attach with your application:
 
* Curriculum Vitae___

* Copies of any licenses you may have____

* Recent photo______

* Processing and registration fee: $50 USD or Philippine Peso Equivalent 

Make Check or Money order Payable to:  

Dr. Florentino M. Berdin, Jr
Cebu Velez General Hospital 
F. Ramos St.
Cebu City 6000
Philippines
Tel. # 920 920 5358
 
 
 
 
Signature:____________________________Date:_________________________
 

THANK YOU FOR YOUR TIME AND ATTENTION.   WE LOOK FORWARD TO
PROVIDING A REWARDING POSITION FOR YOU!   
 
© 2004 Secure Relief Inc.