Employment Application
Which position are you applying to?
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Behavioral Technician
RBT/BCAT
Other
Which location are you applying to?
Fresno/Clovis
Sanger/Reedley/Selma
Madera/Chowchilla
Mendota/Firebaugh
Oakhurst/Coarsegold
Auberry/Tollhouse/Shaver Lake
Are you applying for:
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Full Time
Part Time
Temporary
Other than time off for reasons related to your religion, a disability or a medical condition, are there any days or times when you are unavailable to work?
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Personal Information
Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Education
Highest level of education
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High school diploma, GED
Some college
Associates Degree
Bachelors Degree
Masters Degree
Doctorate/PhD
Highschool
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Name of High School Attended
Number of Years Attended
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Did you graduate?
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Yes
No
Area of Study/Degree
College
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Name of College/University Attended
Number of Years Attended
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Did you graduate?
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Yes
No
Area of Study/Degree
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Graduate School
Name of Graduate School Attended
Number of Years Attended
Did you graduate?
Yes
No
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Did you graduate?
Yes
No
Area of Study/Degree
If hired, would you have a reliable means of transportation to and from work?
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Yes
No
Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)
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Yes
No
Are you able to perform the essential functions of the job for which you are applying, eitherwith or without reasonable accommodation?
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Yes
No
If no, describe the functions that cannot be performed. (Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)
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Employment History
Previous Employer #1
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Name of Previous Employer
Position
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Name of Position
Supervisor Name
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Name of Supervisor
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
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Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
Current employer?
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Yes
No
May we contact this employer for a reference?
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Yes
No
Previous Employer #2
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Name of Previous Employer
Position
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Name of Position
Supervisor Name
*
Supervisor Name
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
*
Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
Current employer?
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Yes
No
May we contact this employer for a reference?
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Yes
No
Previous Employer #3
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Name of Previous Employer
Position
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Name of Position
Supervisor
*
Name of Supervisor
Phone Number
*
-
Area Code
Phone Number
Reason for leaving
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Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
Current employer?
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Yes
No
May we contact this employer for a reference?
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Yes
No
Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Inclusive Hearts, LLC?
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Yes
No
If so, please explain:
References
Professional Reference #1
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Professional Reference #2
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Professional Reference #3
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Availability and Additional Questions
Are you willing to undergo a background check, in accordance with local law/regulation?
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Yes
No
Do you have a RBT/BCAT certification, and able to provide documentation?
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Yes
No
Do you have reliable transportation and a valid Drivers License?
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Yes
No
What days and times are you available?
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Morning-Afternoon
Afternoon-Evening
All day
Unavailable
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Do you speak any languages besides english? If so, please list them.
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Where you referred to us by a current employee?
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Yes
No
If you were referred to us by a current Inclusive Hearts employee, please provide the name of the employee.
Resume Upload
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Browse Files
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Additional Documents (RBT/BCAT certifications, cover letter, etc.)
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Browse Files
Cancel
of
Send Application
Please Read Carefully, and Sign Below
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of myknowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize Inclusive Hearts, LLC to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me
and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the
option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's
designated representative.
In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form
upon hire.
Inclusive Hearts, LLC will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws.
Signature
Date
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Month
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Day
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Date
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