FTAJ Clinical Application

  • Instructions

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

  • Select all that apply
  • Please enter "N/A" if not currently licensed.
  • Enter "N/A" if not currently under supervision.
  • Employment History

    List your last three employers, starting with the most recent one first.
  • Employer #1-Most Recent

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please enter information in the following format: 9,999.99
  • Please enter information in the following format: 9,999.99
  • Employer #2

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please enter information in the following format: 9,999.99
  • Please enter information in the following format: 9,999.99
  • Employer #3

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please enter information in the following format: 9,999.99
  • Please enter information in the following format: 9,999.99
  • Education Information

  • 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.
  • 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.
  • Max. file size: 100 MB.
    Please upload your professional resume.
  • Max. file size: 100 MB.
    Please include at least 3 professional references, including address, phone number, number of years known, and relationship.
  • By signing your name electronically, you agree to the conditions of employment as stated above.