Name Health Worker Retraining Initiative Application Program of Interest * LPN (Licensed Practical Nurse) OTA (Occupational Therapy Assistant) PTA (Physical Therapy Assistant) PT Aide (Physical Therapy Aide) First Name * Last Name * Email Address * Address Line 1 * Address Line 2 City * State * Zip * Home Phone Number Cell Phone Number Most Recent Paid Health Care Experience Position Details Start Date * End Date * Or put "Current" if still employed at this position. Your Title & Responsibilities * Health Care Company Name * Company Address Line 1 * Company Address Line 2 City * State * Zip * Do you have experience with an additional health care position for which you'd like to provide us details? Yes No Are you presently attending school? * Yes No Please check the level(s) of education you COMPLETED and received a Diploma or Degree. * GED HS Diploma Associates Bachelors Masters Are you prevented from lawfully becoming employed in this country because of visa or immigration status? * Yes No Terms I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I also understand that an employee with Audacia will be reaching out to me for additional information pertaining to my work history and current studies (if already enrolled in school).
