H-1 Employee Application

Introduction to the Position

Before Applying, please view the links below to learn more about ABA & Autism.
What is Applied Behavior Analysis?

Learn about Autism

Examples of ABA Sessions:

ABA Session Examples on Youtube
Application for Employment
Full Name*

First NameMiddle InitialsLast Name
Address*

Street Address (include Apt./Unit #:)

Apt./Unit #:

CityState

Zip Code
Position Applying For:
Ex: Registered Behavior Tech, Admin, Other
Type of Position:
E-mail*
Mobile Number*
Are you authorized to work in the United States?*

YesNo
We offer in-home therapy - would you be comfortable working independently in-home with clients*

YesNo
Do you know or are you related to anyone that currently works here?*

YesNo
Do you have reliable transportation, with a valid driver's license and state minimum insurance?*

YesNo
Do you have verifiable, professional experience working with children?

YesNo
RBT Certifications & Training
Are you currently a Registered Behavior Technician? (Note: an RBT is required for this position)*

Yes, I am currently a RBTNo, I am not an RBTNo, but I have completed the 40 hour RBT training and need competency check.My RBT is expired or inactive & I'll have to redo the competency and exam
If you are an RBT, is your certification in good standing without pending investigations?

YesNo
Do you have a current Basic Life Support/CPR certification? (Completed with in-person skills check)*

YesNo
Other certifications, training, and experience you have:
Education
Are you at least 18 years of age and have a high school diploma? Note: When applying to become an RBT, this information will be required.*

YesNo
College/University Education
College / University Name (Most Recent)
*include City, State
Did you graduate?

YesNo
Degree Earned:
Are you enrolled in a BACB approved ABA course sequence?

YesNo
Work History
Employer Name (Most Recent)*
City, State*
Date Started*

MonthDayYear
Date
Date Ended*

MonthDayYear
Date
Position*
Phone Number*

Area CodePhone Number
Reason for leaving?*
May We Contact for a Reference?*

YesNo
Work History #2*
City, State:*
Dates Started*

MonthDayYear
Date
Date Ended*

MonthDayYear
Date
Position*
Reason for leaving?*
Availability

We work on a block schedule system. Our sessions have some flexibility for our client's needs and are offered in 3 hour increments or 2-hour increments as generally noted below.

Select the time frames that you are available to work:

	8:30am-11:30am	12:30pm-3:30pm	4-6:30pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

I need to work a minimum of....(hours per week)
Type your ideal # of hours
I can work no more than....(hours per week)
Note: this is a part time role less then 25hrs per week
Ideally, I want to work... (hours per week)
Note: this is a part time role less then 25hrs per week
I need to make ...(dollars per hour)
Note: Rate is dependent on experience in ABA
Soonest 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 CodePhone Number
Years Known*
Reference # 2 Full Name*
Position*
Email*
example@example.com
Phone Number*

Area CodePhone 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 and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. *

Clear
Applicant Signature
Date Time Signed
Should be Empty:

Introduction to the Position

Application for Employment

RBT Certifications & Training

Education

Work History

Availability

Professional References