EMPLOYMENT APPLICATION

Transcription

1 P.O. Box 5124 Hyattsville, MD (855) EMPLOYMENT APPLICATION Please complete the entire application. Full Home City/State/Zip Number of years at this address: Prior City/State/Zip Number of years at this address: Daytime phone: Evening phone: Mobile phone: Social Security: Driver s License (State/No.) Are you at least 18 years old? q Yes Are you a citizen of the United States: q Yes If, no are you authorized to work in the U.S.? q Yes Have you ever worked for this company? q Yes If yes, when? Have you ever been convicted of a felony? q Yes If yes, explain? Page 1 of 8

2 Position applying for: q Administrative Staff q Behavior Support Staff q Family Trainer/Consultant Date available to begin employment: Areas What areas would you like to work in? All Areas District of Columbia Maryland Virginia Northeast Northwest Southeast Southwest Allegany Anne Arundel Baltimore City Baltimore County Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Arlington County Alexandria Loudoun Fairfax County Prince William Specific Areas Harford Howard Kent Montgomery Prince George's Queen Anne s Saint Mary s Somerset Talbot Washington Wicomico Worcester Time(s) available to work: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Check all that apply q Full time q Part time q Flexible q Nights q Weekends Page 2 of 8

3 Skills Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number that corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.) Ability or Skill Years of Rating Experience Typing Microsoft Office Suite (Word, Excel, etc.) Applied behavior analysis Verbal behavior Special education Intensive individual support services Family training/family Consulting Positive behavior supports Languages Other Other Other Education Type School Course of Study From To (Years) Graduation (Year, if applicable) High School College/ University College/ University College/ University Trade/ Vocational Other Other Page 3 of 8

4 Are you licensed as a Behavior Analyst in any jurisdiction? q Yes If yes, where? Are you a Board Certified Behavior Analyst? q Yes If yes, what is your Certification Number? Are you a Board Certified Assistant Behavior Analyst? q Yes If yes, what is your Certification Number? Are you a Registered Behavior Technician? q Yes If yes, what is your Registration Number? Insurance Qualification Questions Have you ever been refused coverage for professional liability or malpractice insurance or has your malpractice or professional liability insurance ever been canceled or declined for renewal (non-renewed)? q Yes Has any claim or suit ever been brought against you for alleged malpractice or professional liability, or are you aware of ay incident or existing circumstance that might reasonably lead to a claim or suit? q Yes Have you ever been convicted of a misdemeanor or felony? q Yes Have you ever had your license, certification or registration suspended, revoked, or placed on probation by a licensing board, board of examiners, or any other governmental entity that regulates your profession? q Yes Have you received a citation or paid a fine as a result of a board proceeding? q Yes Have you surrendered, either voluntarily or otherwise, your license, certification or registration? q Yes Have you ever been accused of sexual misconduct or any professional impropriety? q Yes Have any complaints ever been filed against you or have there ever been any formal or informal investigations or inquiries opened with a peer review committee or an ethics committee of a professional association, hospital, health care facility, or any other governmental or private entity? q Yes Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set by law, by regulation, by a peer review committee or by an applicable code of ethics in any jurisdiction where you provide services? q Yes Page 4 of 8

5 If your answer to any of the previous questions is yes, please provide a detailed explanation below. Please also provide any pertaining documentation (i.e. Dismissal Letters, Consent Agreements, etc ). In addition, if you have previously reported this on prior applications, or it is already on file with our agency, please indicate so. * Please include a written description of the Yes answer above: Select the ages of the people you have experience providing services to: Early childhood (ages 0 5) Children (ages 5 10) Adolescents (ages 10 18) Young Adults (ages 18 35) Adults (ages 35 65) Seniors (ages 65+) What were the diagnoses of the people you have experience providing services to? Do you have experience working with social groups? q Yes If so, what group sizes do you have experience providing services to? 2 or 3:1 4 or 5:1 Larger Employment History List your current, or most recent, employment first. Please list all jobs (including selfemployment and military service) that you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue on the back page of this application. Employer s Supervisor Job Title: Reason for Leaving: Dates of Employment (Month/Year): Page 5 of 8

6 Employer s Supervisor Job Title: Reason for Leaving: Dates of Employment (Month/Year): Employer s Supervisor Job Title: Reason for Leaving: Dates of Employment (Month/Year): Professional References Telephone Number: Telephone Number: Telephone Number: Page 6 of 8

7 Emergency Contacts Who should we contact if you are involved in an emergency? City/State/Zip Telephone Number City/State/Zip Telephone Number Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer: Page 7 of 8

8 CERTIFICATION I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Breakthrough Developmental Services, LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and either I, or my employer, will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Breakthrough Developmental Services, LLC, except in a specific written contract of employment signed on behalf of the organization by its President, has the power to alter or vary the voluntary nature of the employment relationship. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. Applicant s Signature Date Applicant s Printed Name Breakthrough Developmental Services, LLC is an equal opportunity employer. Your application will be considered without regard to race, age, color, gender, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation, or physical or mental disability. Page 8 of 8