APPLICATION FOR EMPLOYMENT

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1 APPLICATION FOR EMPLOYMENT Colleyville (817) Flower Mound (972) Round Rock (512) Southlake (817) Date: General Information Last Name First Name MI (Maiden Name/Other) Address City State Zip Code Primary Contact Phone # Secondary Contact Phone # Do you have a current Driver s License? Yes, State: DL#: Class: No Do you have any relatives working for Elements Therapeutic Massage? No Yes, name: Relationship: Have you ever worked for Elements Therapeutic Massage? Yes. Dates: to Position: No If hired, can you furnish proof that you are legally entitled to work in the US? Yes No Are you least 16 years of age? Yes No Availability Position(s) you are applying for: Interested in: Full Time Part Time Temporary I will accept: Full Time Part Time Temporary Date Available: Education School Name & Location Dates From To HIGH SCHOOL: Diploma or GED? Yes No TRADE SCHOOL: COLLEGE: OTHER: Credit Hours & Major Certificate/Degree obtained Major / Minor Certificate/Degree obtained Major / Minor DF/14 Page 1 of 6

2 Skills List all types of computers and software programs you have experience with: License, Certificates & Certifications: Honors, Recognition, other Skills and Training: Languages Read Speak Write Read Speak Write Criminal History Elements Massage conducts criminal history checks on all employees. Answer following question in full: (Note: A conviction does not mean that you will not be considered for employment. Your age, date of offense, nature of the violation and rehabilitation will be taken into account.) Have you ever been convicted, placed on deferred adjudication or community supervision, or Pled guilty or no contest to a felony or misdemeanor offense? (Other than to class C traffic violations as listed above) Yes No If NO, mark No and skip this section. If YES, please answer the following questions about each conviction. Arrested: Dates: Locations: What were your charges: Results: Probation or Deferred Adjudication: Starting dates: Finishing dates: Jail or Prison Sentence: Starting dates: Finishing dates: Fine: Amounts $ Please use the back page of this application form to give more information or use a separate sheet and attach to this application. Work Experience (Beginning with the most recent) 1. Employer Dates From Address Telephone To Duties DF/14 Page 2 of 6

3 Work Experience (Beginning with the most recent) Your Job Title Supervisor Wage/Salary Start End (continued) Reason for Leaving 2. Employer Dates From Address Telephone To Duties Your Job Title Supervisor Wage/Salary Start End Reason for Leaving 3. Employer Dates From Address Telephone To Duties Your Job Title Supervisor Wage/Salary Start End Reason for Leaving If you are currently employed, may we contact your employer? Yes No Future Education Are you planning to pursue further studies? Yes No If yes, when, where, what and what courses? List any organizations you belong to, Hobbies, or Special Interests DF/14 Page 3 of 6

4 Read Carefully Before Signing I certify that all the answers I have given are true to the best of my knowledge and belief. I understand that any falsifications, misrepresentations or omission of facts in this application may be cause for my elimination from consideration for hire, or, if already hired, cause for my dismissal, regardless of the time that passes before such false information is discovered. I further acknowledge that I have read and understand the questions regarding criminal records and I have answered these questions truthfully. I expressly request employers and any persons who may have information (including records of criminal convictions) concerning me, furnish that information to the Human Resources Department and agree to hold such persons harmless, and I do hereby release them of any and all liability or damage of any nature whatsoever for furnishing such information. I understand that the information obtained is for Elements Massage use and may be disclosed to third parties as required by law. I understand that I may be required to complete a physical examination and drug/alcohol screening, at Elements Massage s expense, after a conditional offer of employment. If a doctor determines I have certain medical restrictions relating to my ability to perform the job I applied for, those restrictions will be communicated to the Human Resources Department of Elements Massage for the purpose of determining my ability to perform the essential functions of the job with or without any reasonable accommodation. I understand and agree that employment with Elements Massage is "at will" and for no definite period of time and that wage, benefits and conditions of employment can be changed at any time. I understand that this is not an employment contract between Elements Massage and me. Elements Massage will reject any application which is unsigned or graphically altered. Signature: Date: Note/additional information DF/14 Page 4 of 6

5 Therapist Application Questionnaire Name: Date: 1. A client complains of low back pain. You have massaged their low back and gluteus muscles and they are still in pain. What other muscle(s) should you address? 2. You have a client who works on the computer all day. They have significant upper back, neck and shoulder pain. What muscle groups are you going to be sure to massage? 3. A client complains of a tension headache. Which muscle groups/areas of the body are you going to be sure to address first? 4. A client has a migraine headache. How will you address this in your massage? What instructions will you give them for easing the migraine at home? Heat/Ice? Where? Pressure points they can active? Where? 5. A client has been in an automobile accident. How soon after the accident would you give their first massage? Would you recommend chiropractic treatment? 6. The same client has suffered whiplash during the automobile accident. What muscle(s) (besides the sternocleidomastoid) would you address? 7. With a prenatal client what is the best positioning after 22 weeks? What areas should you not massage? Why would deep tissue massage be contraindicated? DF/14 Page 5 of 6

6 EEOC Statement Elements Massage is an equal opportunity employer. The commitment of Elements Massage is to a policy of equal employment opportunity requires that certain information be gathered and documented for statistical purposes only. The following information is requested for Human Resources use only in order to assist us in complying with EEO reporting guidelines. This information will be kept separately from the applicant's files and will not be used as a basis for making employment or upon employment will not be used for any subsequent personnel decision. This form is optional Ethnic Group White (Not of Hispanic origin) - All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. Black (Not of Hispanic origin) - All persons having origins in any of the Black racial groups of Africa. Hispanic - All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin. Other Asian or Pacific Islander - All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Samoa. American Indian or Alaskan Native - All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Sourcing Information Please complete the following information to help us determine our advertising effectiveness. You heard about this position from: Elements Website Friend/Family University Career Services Massage School School Name: Dallas Morning News Ft. Worth Star Telegram Library Professional Craigslist.com Monster.com Jobing.com Salonpost.com Other (be specific): DF/14 Page 6 of 6

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