Exstrom Physical Therapy > Our Clinic > Shadowing/Internship Information > Job/Shadow/Internship Application Job/Shadow/Internship Application Your Information First Name * Last Name * Address * City * State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Phone * Email Address * Employment Information What position are you applying for? * Shadowing Experience for High School Credit Shadowing Experience for College Credit Interning Experience Job - Physical Therapy Tech Job - Office Staff Job - Professional Staff Employment Desired * Full Time Part Time Full or Part Time Days and Times Available to Work * Please list the days, start and end times you are available to work How many hours would you prefer to work per week? * 1-5 6-10 11-20 21-30 31-40 Date you would be able to start: * Previous Education * Please list all High School, College, Business/Trade, Professional/Graduate school you have completed What experiences/talents would you bring to this clinic? * Previous Employment Previous Employer 1 * Supervisor * Employed From * Employed To * Position * Weekly Hours * Pay * Job Duty Description * Reason for Leaving * Previous Employer 2 Supervisor Employed From Employed To Position Weekly Hours Pay Job Duty Description Reason for Leaving Previous Employer 3 Supervisor Employed From Employed To Position Weekly Hours Pay Job Duty Description Reason for Leaving References Reference 1 Name (First and Last) * Relationship * Phone Number * Email Address * Reference 2 Name (First and Last) * Relationship * Phone Number * Email Address * Reference 3 Name (First and Last) * Relationship * Phone Number * Email Address * Attestation Are you of legal age to work in the state of NE? * Yes Have you ever been convicted of a crime? * No Yes Please explain in detail Questions If you are applying for shadowing, an internship or a PT Tech position, please tell us * 1. Why are you interested in the field of Physical Therapy? 2. What do you hope to gain from the experience? 3. What are your short and long term educational and career goals? Why do you believe you would be a great addition to our clinic? What skills or talents set you apart from other applicants? * reCAPTCHA If you are human, leave this field blank.