Employee Application

Employee Application
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What position are you applying for?
Please provide relevant past job experiences.
What interests you about this position?
Do you have experience working and/or playing with children? Please explain.
Have you ever worked in the field of ABA before?
Hours you are looking for
Requested Hourly Rate
Do you need benefits?
Position type: Full or Part Time
Availability

Please list all times you are available to work.
Monday (start and end time)
Tuesday (start and end time)
Wednesday (start and end time)
Thursday (start and end time)
Friday (start and end time)
Saturday (start and end time)
Do you have current CPR training?
CPR Certificate

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If yes, what was the date of training?
Do you have current crisis management training?
Do you have a current KS driver license?
Do you have reliable transportation?
Have you ever worked in client homes before?
Do you agree to a background check?
Do you have pending criminal charges?
I understand it is my responsibility to report all criminal charges including charges that are pending as well as arrests from the time of submitting this application moving forward.

YesNo
Can you legally work in the United States?
What is your highest level of education?
Please attach your resume.

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Reference Name

First NameLast Name
Reference Email
example@example.com
Reference Phone Number
Please enter a valid phone number.
Reference Name

First NameLast Name
Reference Email
example@example.com
Reference Phone Number
Please enter a valid phone number.
Reference Name

First NameLast Name
Reference Email
example@example.com
Reference Phone Number
Please enter a valid phone number.
If offered a position, what is your preferred start date? If applicable, how much notice do you need to give your current employer?
I attest all information provided in this document are true and complete, and any
misrepresentation or omission may be grounds for rejection of the applicant or for
dismissal if he or she is employed.
Signature

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Employee Application

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