FTAJ Clinical Application

Instructions

Please fill out all fields in each section entirely. Applicants with incomplete applications will not be considered.

Personal Information

Full Name*

Position Applied for:*

Phone-Home*

Phone-Cell*

Address

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

Email*

Enter Email Confirm Email

Are you legally authorized to work in the United States?*

Yes
No

Are you willing to work:*

Select all that apply

Have you ever applied to work at FTAJ?*

Yes
No

Do you have any prior relationship with FTAJ that might be considered a conflict of interest?*

Yes
No
Unsure

Do you currently hold a valid Florida license as a mental health provider (fully licensed or registered intern status)?*

Yes
No

What is your Florida license number?*

Please enter "N/A" if not currently licensed.

Are you currently under supervision of an approved supervisor?*

Yes
No

If yes, please enter name and license number of your supervisor*

Enter "N/A" if not currently under supervision.

When you could start employment?*

How did you hear about this position?*

Employment History

List your last three employers, starting with the most recent one first.

Employer #1-Most Recent

Present or Last Position

Name of Company

Start Date

End Date

Address

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

Duties:

Reason for leaving:

Starting Annual Salary

Please enter information in the following format: 9,999.99

Final Annual Salary

Please enter information in the following format: 9,999.99

Bonus

Commission

May we contact your supervisor?

Yes
No

Name of supervisor:

Title & department of supervisor:

Phone number of supervisor:

Employer #2

Position

Name of Company

Start Date

End Date

Address

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

Duties:

Reason for leaving:

Starting Annual Salary

Please enter information in the following format: 9,999.99

Final Annual Salary

Please enter information in the following format: 9,999.99

Bonus

Commission

May we contact your supervisor?

Yes
No

Name of supervisor:

Title & department of supervisor:

Phone number of supervisor:

Employer #3

Position

Name of Company

Start Date

End Date

Address

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

Duties:

Reason for leaving:

Starting Annual Salary

Please enter information in the following format: 9,999.99

Final Annual Salary

Please enter information in the following format: 9,999.99

Bonus

Commission

May we contact your supervisor?

Yes
No

Name of supervisor:

Title & department of supervisor:

Phone number of supervisor:

Education Information

High School or GED

City

State

Did you receive a diploma?

Yes
No

College

City

State

Major

GPA

Month and Year of Graduation*

Graduate School

City

State

GPA

Major

Month & Year of Graduation

Graduate School

City

State

Major

GPA

Month and Year of Graduation

What specific qualifications do you have for the position?

What business equipment can you operate (example: computer, copiers, etc.)

Are you able to travel?

Yes
No

Any limitations on your travel?

In what software are you proficient? List the names of programs or special certifications.

Have you ever been refused coverage for professional liability or malpractice insurance or has your malpractice or professional liability insurance ever been canceled or declined for renewal (non-renewed)?*

Yes
No

Has any claim or suit ever been brought against you for alleged malpractice or professional liability, or are you aware of any incident or existing circumstances that might reasonably lead to a claim or suit?*

Yes
No

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

Yes
No

Have you ever had your license, certification or registration suspended, revoked, or placed on probation by a licensing board, board of examiners, or any other governmental entity that regulates your profession?*

Yes
No

Have you received a citation or paid a fine as a result of a board proceeding?*

Yes
No

Have you surrendered, either voluntarily or otherwise, your license, certification, or registration?*

Yes
No

Have any complaints ever been filed against you or have there ever been any formal or informal investigations or inquiries opened with a peer review committee or an ethics committee of a professional association, hospital, health care facility, or any other governmental or private entity?*

Yes
No

Have you ever been accused of sexual misconduct or any professional impropriety?*

Yes
No

Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set by law, by regulation, by a peer review committee or by an applicable code of ethics in any jurisdiction where you provide services?*

Yes
No

Please provide your expected salary range:*

Are your salary expectations negotiable?*

Yes
No

Cover Letter*

Max. file size: 100 MB.

Please upload your cover letter, in which you specifically address why you wish to serve in this role, how your skills and experience have uniquely qualified you for this position, and salary requirements.

Cover Letter*

Max. file size: 100 MB.

Please upload your cover letter, in which you specifically address why you wish to serve in this role, how your skills and experience have uniquely qualified you for this position, and salary requirements.

Resume*

Max. file size: 100 MB.

Please upload your professional resume.

References*

Max. file size: 100 MB.

Please include at least 3 professional references, including address, phone number, number of years known, and relationship.

Conditions of Employment*

By checking this box, you are agreeing to the conditions of employment as stated below.

Conditions of employment:

1. I authorize the investigation of all statements contained in this application. I understand that misrepresentation or material omission of facts is cause for dismissal, whenever such falsification or omission is discovered. I authorize all my previous and current employers and references to furnish any information concerning my personal character, habits or employment records. I release all such persons from liability or damages incurred as a result of this inquiry and furnishing this information. I further understand that any information omitted from this application could be considered grounds for immediate termination.

2. I understand and agree that my employment is for no definite period and may be terminated by me or Family Therapy Associates of Jacksonville, LLC (FTAJ) at any time, for any reason, with or without cause or previous notice, regardless of the date of payment of my wages and salary. I also acknowledge that any offer of employment or my acceptance of any employment offer, may be withdrawn for any reason at any time, and without prior notice at the option of FTAJ or me. No one can create a contract of employment either expressed or implied except in writing specifically to me.

3. If employed by FTAJ, I will comply with all rules, regulations, and directives. I further understand that these rules and regulations may be changed, interpreted, withdrawn, or added to by FTAJ at any time, at FTAJ’s sole option and without any prior notice to me.

4. In making this application for employment, I understand that a routine investigative report may be made. This inquiry includes information as to my character, general reputation, employment, personal characteristics, and mode of living, whichever may be applicable. In addition, the report includes a criminal record check, driver’s license check, education verification, and a public records check. I further understand that obtained as part of this report may be considered grounds for immediate termination.

5. I voluntarily agree to submit to a drug test as part of my application for employment, if requested to do so. I understand that refusal to submit to the test or failure to pass the test according to the standards established by FTAJ will disqualify me from further consideration for employment. I further understand that I may again be required to submit to a drug test during my employment with FTAJ and if I refuse to take the test or fail to pass it according to the standards set by FTAJ, I may be suspended or terminated immediately.

Electronic Signature*

By signing your name electronically, you agree to the conditions of employment as stated above.

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FTAJ Clinical Application

Instructions

Personal Information

Employment History

Employer #1-Most Recent

Employer #2

Employer #3

Education Information

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