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Profile Information
*Last Name: *First, MI:
*Address: *Primary Ph:
 
*City:  Alt Ph 1:
*State:  Alt Ph 2:
*Zip Code:
*Email:

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*How were you referred to StaffRehab?  

If you have been referred by an employee or friend, please provide his/her name and/or email:
First NameLast NameEmail


Additional Documents


Click Here to upload additional documents, such as cover letter, reference letter, licensure, etc



Skills/Core Competencies
This is a two step process. Click on the check box next to each skill category that is applicable to your qualifications. After selecting each category, additional specific skills will appear. Please indicate which specific skills are representative of your abilities and experiences. Please, only select a skill if you consider it one of your core competencies.
Skill Category Specific Skills
 
 SPED Teacher 


EEO Information
To assist in gathering statistical information required to demonstrate StaffRehab's compliance with Equal Employment Opportunity laws, completion of this information is strictly voluntary. Neither the information contained in the form nor your decision not to fill out this form will be considered in arriving at a decision regarding your employment. This information will be filed separately from your employment application.

(I) Please check the race or ethnic group to which you belong:

(1) Asian
 
(2) Black or African American
 
(3) Hispanic or Latino
 
(4) I decline to answer
 
(5) Native American or Alaskan Native
 
(6) Native Hawiian or Other Pacific Islander
 
(7) Two or More Races
 
(8) White
 

(II) Please indicate if you belong to either of the two groups listed below:

Vietnam Veteran - (a) A person who served more than 180 days of active military, navy, or air service, any part of which was during the period of August 5, 1964 through May 7, 1975, and who (1) was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty because of a service-connected disability if any part of his or her active duty was between August 5, 1964 and May 7, 1975. (b) A person who served more than 180 days of active military, navy, or air service, who served within the Republic of Vietnam, any part of which was during the period of February 28, 1961 through May 7, 1975, and who (1) was discharged or released with other than a dishonorable discharge, or (2) was discharged or released from active duty because of a service- connected disability if any part of his or her active duty was between February 28, 1961 and May 7, 1975.
 
Other Protected Veteran - A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.
 
Special Disabled Veteran - A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans Administration for a disability (1) rated at 30 percent or more, or (2) rated at 10 to 20 percent in the case of a veteran who has been determined under section 3106 of Title 38, U.S.C., to have a serious employment handicap or (B) a person who was discharged or released from active duty because of a service-connected disability.
 
Recently Separated Veteran - A veteran who served on active duty in the US military, ground, naval, or air service during a one-year period beginning on the date of a veterans' discharge or release from active duty.
  If recently seperated vet, please provide discharge date: