Application Registered Behavior Technician
With Golden Rule ABA
First Name
Last Name
Current Address
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State/Province
Zip/Postal Code
Phone
Email
example@example.com
Professional Licenses & Certifications:
For each license/certification, list license type, issuing authority, issue date, and expiration date. Also include any CPR/AED/First Aid training certifications you currently hold. (Scan and email copies of all current licenses and applicable certificates with CV to goldenruleaba@gmail.com
Are you RBT certified?
Yes
No
Are you willing to go through the training and exams to become certified?
Yes
No
Position and Compensation:
Desired position
Desired Earnings
Desired Work Load
Part time
Full time
On Call / As Needed
Desired Work Schedule
Mornings
Afternoon
Evenings
Weekends
How would you like to be paid?
Mailed check
Direct deposit
When are you available to start?
Eligibility:
Are you eligible to work in the United States?
Yes
No
Are you at least 18 years of age?
Yes
No
You must be at least 18 years of age to apply for this position. If you will soon turn 18 years, please explain that in the space below.
Do you currently hold a valid unexpired drivers license?
Yes
No
Do you have a reliable vehicle?
Yes
No
Are you willing to drive to client homes?
Yes
No
In the following space, provide additional information in response to any items above that warrant further explanation. Please be as specific as possible.
Have you ever been convicted of a crime? This includes any misdemeanor or felony offenses.
Yes
No
Please explain any convictions, list the offense, date, location, and age at the time of conviction. Please note that having a record of conviction does not preclude employment. Various factors will be taken into account, such as: the age at the time of the offense, type of offense, history of rehabilitation, and relevance to the job for which you are applying.
References:
Please provide the names, titles, and contact information of ONE personal reference and THREE professional references.
Personal Reference
First Name
Last Name
Phone
Who is this person to you? Describe how you know this person. Indicate how long you have known this person and what you predict this person might say about you.
Professional Reference #1
First Name
Last Name
Title & Organization
Location
City/State
Phone
Relationship; describe how you know this person. Indicate how long you have known this person and whether this person has directly observed your work performance. If not, explain why this person should serve as a good reference for.
Professional Reference #2
First Name
Last Name
Title & Organization
Location
City/State
Phone
Relationship; describe how you know this person. Indicate how long you have known this person and whether this person has directly observed your work performance. If not, explain why this person should serve as a good reference for.
Professional Reference #3
First Name
Last Name
Title & Organization
Location
City/State
Phone
Relationship? Describe how you know this person. Indicate how long you have known this person and whether this person has directly observed your work performance. If not, explain why this person should serve as a good reference for.
Supplemental Information
Many applicants choose to provide potential employers with their Linkedln or other professional profiles that positively showcase their work or achievements. If you would like to share yours for our review, please provide the direct links to your page here:
Cover Letter and/or resume (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attestation:
By checking this box, you indicate that the materials submitted as part of this application are verifiably accurate and all information provided herein and to be provided via email is, to your best knowledge, true.
Read and understood.
By checking this box, you certify that you have no criminal background that would preclude you from passing a background check which may involve fingerprint testing.
Read and understood.
By checking this box, you certify that you have no criminal background that would preclude you from passing a background check which may involve fingerprint testing.
Read and understood.
By checking this box, you are granting permission to contact any and all references you provide on your behalf.
Read and understood.
Applicant signature
Printed name of applicant
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: