Employment Application Form

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We are an equal opportunity employer, dedicated to a policy of non-discrimination on any basis including race, color religion, creed, national origin, age, veteran status, marital status, citizenship, disability, or any other characteristics protected under the law.

Logo Join our team! We are looking for energetic, patient and caring people to work with people with autism and related disabilities. Part-time positions offer great flexibiilty, working around your schedule. Full-Time employees have the option of health insurance, flexible medical spending accounts and a 401k retirement program. If chosen to as a team member, various background checks and training will be required and provided by us at no cost to you.

Good luck!

Your Information

First Name *

Middle

Last Name *

Address *

City *

ZIP Code *

State *

Home Telephone

Other Telephone

Were you employed previously by us? * YesNo

When?

Position Desired

Date Available *

Position Applying For * Residential ProgramApplied Behavioral (ABA) Program

Wage Information

I understand that the base pay rates for these positions are as follows:

Residential Program

Direct Care Team $9.36/hour (Part or full time)

Applied Behavioral Program

Line Therapist $10/hour (Part-time, 10 to 30 hours per week)

Lead therapist $14/hour (Part or full-time, requires 500 hours experience as a Line Therapist)

I understand the above * YesNo

Type * Full-timePart-Time

-Applied Behavioral (ABA) positions are part-time. Therapists average 15 hours per week. Residential positions may be part or full-time.

Hours you CANNOT work.

Skill

Select the method which best explains how you found out about this job

Please specify:

References

List persons who know your work professionally, excluding supervisors

Reference

Name

Organization/Position *

Telephone

Relationship *

Years Known *

(Rounded to the nearest year)

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Education requirements:

High School Diploma AND
College Degree or presently enrolled in college (2 years college preferred).

Remember:

You must have a college degree or be enrolled in college

Education

High School

Name *

Location

Diploma Received? YesNo

College/University

Name *

Location

Major

Degree Received

Other Education

Name

Location

Training Received

Employment History

Please list most recent employer first

Employer

Company Name

Company Address

Company Phone

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name

Supervisor's Position

Starting Salary

Ending Salary

Your Duties

Reason for Leaving

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If there have been any gaps in your employment during the last five years, please provide details in the space provided here:

List professional, trade, business or civic activities and offices held. Describe any specialized training, apprenticeship, skills and extracurricular activities (excluding those which, by their name or character, indicate the race, color, religion, sex, age, national origin, marital status, ancestry or handicap).

Summarize special training skills (such as machines, typing, PC skills, language skills, etc.) which you feel may especially qualify you for working with our agency.

Applicant's Statement

I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application or in any interview is sufficient cause for refusal to hire, or dismissal if I have been employed,
no matter when discovered. Please note that all information is subject to verification.
I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be "at-will" and without fixed term, and may be terminated at any time, with or without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing by an authorized Company official.
If I am offered employment I agree to submit to a medical examination and/or drug test before starting work. If employed, I also agree to submit to a medical examination and/or drug test at any time deemed appropriately by the Company and as permitted by applicable law. I consent to such examinations and/or tests, and I request that the examining doctor disclose to the Company the results of the examination, which the Company shall keep confidential. I understand that my employment or continued employment, to the extent permitted by applicable law, is contingent upon satisfactory medical examinations and/or drug test.
I understand that employment is contingent upon my complying with the employment verification requirements of the Immigration Reform and Control Act.

I certify that I have read, or have had read to me, items 1, 2, 3, 4 and 5 above. I understand the contents and hereby acknowledge receipt of this information.

I agree to the above; * YesNo

Are you capable of performing, with or without reasonable accommodation, the essential functions of the job or occupation for which you have applied? * Yes
No

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