[PDF]MASSAGE EMPORIUM, LLC. Massage Therapist...
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MASSAGE EMPORIUM, LLC. Massage Therapist Application Name:_________________________________ Today’s Date_____________ Address:____________________City________________State____ Zip_______ Phone:______________________Email________________________________ Are you eligible to work in the United States? Yes____ No____ Social Security # :________________Drivers License #:___________________ Have you ever been convicted of a felony? Yes____ No____ If yes, please explain_______________________________________________ How did you hear about Massage Emporium/ The job opening? ________________________________________________________________ Do you have any friends or relatives employed by us? If so, who? ________________________________________________________________ Have you previously applied or worked for the Massage Emporium and when? ________________________________________________________________ Are you presently employed, if so where? ________________________________________________________________ May we contact your employer? Yes____ No____
Date available to start work:_______________ List available Days, and Times available for work (Mon-Sun, 7am-9pm) ________________________________________________________________ ________________________________________________________________ Are you a licensed Massage Therapist in the state of Louisiana? Yes____No_____ Massage License #_____________________Expiration date______________ (Photocopy required on start date) If Not licensed, when do you expect to be licensed? ____________________ Liability Insurance Provider:________________________________________ Liability insurance Policy#____________________exp date______________ (Photocopy required on start date)
EDUCATION SCHOOL ATTENDED
NAME/ADDRESS/PHONE
GRADUATED
HIGH SCHOOL
YES__NO__
COLLEGE/UNIVERSITY
YES__NO__
MASSAGE/TECHNICAL/ VOCATIONAL
YES__NO__
COURSE/MAJOR
________________________________________________________________ How many hours of massage Training have you had? _____________________ Where did you receive your training? __________________________________ How long have you been practicing massage? ___________________________ Have you had specific training in chair massage? ________________________ Certifications, CPR Training, Special Training, Seminars, Workshops, Etc: ________________________________________________________________ ________________________________________________________________ Professional Associations/Technical Affiliations___________________________ ________________________________________________________________ What Modalities of massage are you trained to practice? (Ex: Swedish, deep tissue, pre-natal, sports, shiatsu, hot stone, reflexology, etc.) ________________________________________________________________ _______________________________________________________________ Foreign Languages:_______________________________________________ Other Skills:______________________________________________________ Special Interests:_________________________________________________
EMPLOYMENT Please list all jobs, military service and/or self-employment beginning with present. COMPANY NAME ADDRESS & PHONE#
DATES OF EMPLOYMENT
RATE OF PAY
Hire Date
Starting $
Last Day
Finishing $
POSITION/DUTIES NAME OF SUPERVISOR
REASON FOR LEAVING
_____________________________________________________________________________ Hire Date
Starting $
Last Day
Finishing $
_____________________________________________________________________________ Hire Date
Starting $
Last Day
Finishing $
_____________________________________________________________________________
Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodations? YES______NO_______ If no, please explain what accommodations you require: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
REFERENCES List below three persons not related or residing with you who are willing to provide professional reference: 1. Name ________________________________Phone # _____________________ Email________________________________Years Aquainted_______________ Title and/or relationship _____________________________________________ 2. Name ________________________________Phone # _____________________ Email________________________________Years Aquainted_______________ Title and/or relationship _____________________________________________ 3. Name ________________________________Phone # _____________________ Email________________________________Years Aquainted_______________ Title and/or relationship _____________________________________________
I certify that information in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of independent contractor agreement at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature _________________________________________ Date _______________________
_____________________________________________________________________________
Office use only: Scheduled Interview Date: ___________________________ nd
by: _______________________
2 Interview Date: _________________________________
by: _______________________
Decision:_________________________________________
by: _______________________
Additional Notes: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
