Employee Application

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
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? *
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 *
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
Date Time Signed
Optional - Attach a Resume

Browse Files

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Application for Employment

RBT Certifications & Training

Education

Work History

Availability

Professional References