Application for Employment
Full Name
*
First Name
Middle Initials
Last Name
Address
*
Street Address (include Apt./Unit #:)
Apt./Unit #:
City
State
Zip Code
Position Applying For:
E-mail
*
Mobile Number
*
Are you authorized to work in the United States?
Yes
No
Have you ever applied for employment with us?
Yes
No
Do you know or are you related to anyone that currently works here?
Yes
No
Do you have reliable transportation, with a valid driver's license and state minimum insurance?
Yes
No
If hired, would you have access to a computer with internet to complete training?
Yes
No
RBT Certifications & Training
Are you currently a Registered Behavior Technician? (Note: an RBT is required for this position)
Yes
No
No, but I have completed the 40 hour RBT training and need competency check.
My RBT is expired or inactive
Is your certification in good standing without pending investigations?
Yes
No
Do you have a current Basic Life Support/CPR certification? (Completed with in-person skills check)
*
Yes
No
Other certifications, training, and experience you have:
Education
Are you at least 18 years of age and have a high school diploma?
*
Yes
No
High School Name/City/Location
*include City, State
Did you graduate?
Yes
No
Date of Graduation (Month/Year)
College/University Education
College / University Name (Most Recent)
*include City, State
Did you graduate?
Yes
No
Degree Earned:
Are you enrolled in a BACB approved ABA course sequence?
Yes
No
Work History
Employer Name (Most Recent)
City, State
Date Started
-
Month
-
Day
Year
Date
Date Ended
-
Month
-
Day
Year
Date
Position
Phone Number
-
Area Code
Phone Number
What did you like & dislike about this job?
May We Contact?
Yes
No
Work History #2
City, State:
Dates Started
-
Month
-
Day
Year
Date
Date Ended
-
Month
-
Day
Year
Date
Position
What did you like & dislike about this job?
Organizational Values & Career Goals
Of the choices below, what are 3 things you value the most?
Meaningful Work
Flexibility
Being accountable
Making a difference
Being positive
Tolerance & Accepting
Integrity
Having Fun
Taking Risks
Taking charge
Making Money
How does this RBT position help you to achieve your long term goals?
Availability
Select the time frames that you are available to work:
8:30-11:30am
12:30-3:30pm
4:00-6:00pm
Monday
Tuesday
Wednesday
Thursday
Friday
I need to work a minimum of....(hours per week)
Type your ideal # of hours
I can work no more than....(hours per week)
Type maximum # of hours you can work
Ideally, I want to work... (hours per week)
Please be honest - how many hours do you really want?
I need to make a minimum of...(dollars per hour)
Type lowest pay rate here. Note: we pay based on a matrix of education, training, and experience.
Date I can start
Professional References
Please only include professional references - no friends or family members.
Reference # 1 Full Name
Position
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Years Known
Reference # 2 Full Name
Position
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Years Known
Applicant Signature
Clear
Date Time Signed
Optional - Attach a Resume
Browse Files
Cancel
of
Please give us some dates/times that you are available for an interview within the next week.
EMPLOYMENT APPLICATION DISCLAIMER AND ACKNOWLEDGEMENT. I certify that the information contained in this application is correct to the best of my knowledge.
*
Applicant Signature
Clear
Submit
Should be Empty: