Epic Strides Employee Application

Epic Strides Employee Application

4105 W Spring Creek Pkwy STE 602/614 Plano, TX 75024
Personal information
First Name:
Middle Name:
Last name:
Date of Birth:

MonthDayYear
Date
Email Address:
example@example.com
Requested hourly pay: *
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Do you consent to receiving text messages at this phone number?*

Yes, I consentNo, I do not consent
Are you eligible to work in the United States?

YesNo
If you are under the age of 18, do you have an employment/age certification?

YesNon/a
Have you ever been convicted of a felony? “Answering “yes” to this question will not automatically bar you from employment unless applicable law requires such action.”*

YesNo
Have you ever pled guilty or no contest to a felony, or subjected to deferred adjudication on a felony charge? “Answering “yes” to this question will not automatically bar you from employment unless applicable law requires such action.”*

YesNo
If you answered "Yes," to either of the questions above explain in reasonable detail below, giving dates and nature of the offense, name and location of the court, and disposition of the case(s). A conviction may not disqualify you, but a false statement will. Note: We may require additional information related to convictions of misdemeanors:
Position/availability:
Position applied for:
Days and times available:
Monday: *
Tuesday: *
Wednesday: *
Thursday: *
Friday: *
What date are you available to start work: *

MonthDayYear
Date
“I understand that the position I applied for may or may not be available depending on the changing needs of the employer. I understand that certain aspects of my employment, if obtained in connection with this application, will be subject to the changing needs of Epic Strides which may result in changes to certain aspects of the employment relationship, such as compensation, responsibilities, location, etc.”
Initials
Education:
Name of Highschool:
Did you receive your High school diploma?
Graduation date:
Name of college:
Degree:
Did you graduate?
Graduation date:
Do you have any certifications? (RBT, SLP, etc..)
Employment History:
Current/last employer
Address:
Dates employed from:
Supervisors name:
Phone number:
Email:
What was your position title?
Salary:
Please list responsibilities:
Reason for leaving:
May we contact this employer?
Previous employer:
Address:
Dates employed from:
Supervisors name:
Phone number:
Email:
What was your position title:
Salary:
Please list responsibilities:
Reason for leaving:
May we contact this employer?
Experience:
Do you have prior clinical experience in ABA?

YesNo
If yes, what type of experience do you have in the field of ABA (check all that apply)

Center basedHome basedSchool basedOther
Will you be seeking BCBA Supervision?

YesNo
Who referred you to Epic Strides? (If online site, please list which site)
Do you know a current employee working at Epic Strides?*

YesNo
If you answered yes to the above question please list the employee's name below.
Are you currently under a contract that you would be breaching by accepting this position? *
Emergency Contact:
Name of Emergency contact:
Relationship:
Phone number:
I understand that the position I am applying for with Epic Strides requires that I interact with patients in sensitive scenarios, with special needs, and in connection with certain behavioral and academic services. Further, I understand that, due to the sensitive nature of the company’s clientele, certain information which may arise on a background or similar check may disqualify me from being able to perform the position I am applying for. Nevertheless, I understand, acknowledge, and agree that Epic Strides may obtain a background check of that sort in connection with this employment application. I understand that Epic Strides may check with the Texas Department of Public Safety, the Federal Bureau of Investigation, or other organizations, for any criminal history in accordance with applicable statutes, and may have a general background check put together in connection with this application. I understand that as a part of this application, Epic Strides may request and obtain a background check which may include certain information regulated by the Federal Trade Commission. I approve of Epic Strides’ procurement and review of such information, and have been made aware of my rights in connection therewith. https://consumer.ftc.gov/credit-loans-and-debt/credit-and-debt*
Initials
I CERTIFY THAT ALL THE INFORMATION PROVIDED BY ME IN CONNECTION WITH MY APPLICATION, WHETHER ON THIS DOCUMENT OR NOT, IS TRUE AND COMPLETE, AND I UNDERSTAND THAT ANY MISSTATEMENT, FALSIFICATION, OR OMISSION OF INFORMATION MAY BE GROUNDS FOR REFUSAL TO HIRE OR, IF HIRED, TERMINATION.
Name (printed)
Signature:

Clear
Date:

MonthDayYear
Date
It is the policy of Epic Strides not to discriminate against any applicant for employment, or any employee because of age, color, sex, disability, national origin, race, religion, veteran status or other protected class.
Should be Empty:

Epic Strides Employee Application

Personal information

Position/availability:

Days and times available:

Education:

Employment History:

Experience:

Emergency Contact: