Online Application for Employment Educational Assessment Systems, Inc.

EASi considers prospective employees without discrimination because of race, creed, sex, age, national origin or handicap.

* =required fields

Personal Information
Last Name
 *
First Name
 *
Middle Initial
How did you learn about EASi
Social Security
Email Address
Phone Number
Cell Number
Street Address
 *
City
 *
State
 *

Zip

 *
* Professional Discipline
Educational Diagnostician OT
School Psychologist PT
SLP-CCC CFY
 * Have you ever been convicted of a crime other that a minor traffic violation?
Yes
No
Are you a citizen of the US?
Yes
No
 
If No, Country of Origin
Describe Your Employment and Location Needs.

Professional and Educational Information
* Licenses, Registrations or Certifications, please list name, number, renewal date.
* Have you ever been named as a defendant in a professional liability action?
Yes
No

If Yes, Explain.
Has your professional license ever been investigated or suspended?
Yes
No

If Yes, Explain.

Education
University / College
Name
Month /Year
 /
Diploma Received
University / College
Name
Month /Year
 /
Diploma Received
Graduate School
Name
Month /Year
 /
Diploma Received
Graduate School
Name
Month /Year
 /
Diploma Received

Employment History
We do no contact your places of employment without your written or verbal permission.
Are You Currently Employed?
Yes
No
Beginning with present or last employer, please complete the following
Employer Name
Address
Supervisor
Phone
Job Title
Start Month / Year
/
Finish Month / Year
/
Reason For Leaving
2nd to Last Employer
Employer Name
Address
Supervisor
Phone
Job Title
Start Month / Year
/
Finish Month / Year
/
Reason For Leaving
3rd to Last Employer
Employer Name
Address
Supervisor
Phone
Job Title
Start Month / Year
/
Finish Month / Year
/
Reason For Leaving
4th to Last Employer
Employer Name
Address
Supervisor
Phone
Job Title
Start Month / Year
/
Finish Month / Year
/
Reason For Leaving

References
1st Reference
We do not contact references until you give us your written or verbal permission.
Name
Phone
Years Known
Occupation or Place of Work
Relationship
2nd Reference
Name
Phone
Years Known
Occupation or Place of Work
Relationship
3rd Reference
Name
Phone
Years Known
Occupation or Place of Work
Relationship

Agreement
I hereby authorize Educational Assessment Systems, Inc. to contact previous employers and to investigate and verify the facts stated by me in this application. *
Yes
No, not at this time
I hereby declare that the information provided by me in this application for employment is true, correct, and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I understand that if I am considered for employment, I will be subject to a criminal records check.
* MM/DD/YY
 / / Due to the high number of applications carrying
viruses, if you don't get a reply that we have received your
application, it most likely was diverted. Email Suzanne Poirier for direct confirmation.