Employment Application Form
What position are you interested in?
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Administrative
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Personal Information
Name
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First Name
Last Name
Phone Number
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Email
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Sex
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Date of birth
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Day
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Age
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I confirm I have at least 18 years of age
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Yes, I'm over 18 years old
Address
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Street Address
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City
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Postal / Zip Code
Are you eligible to work in the United States?
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Yes, I can work in the US
Do you have a valid, unexpired Driver's License?
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Yes, I have a valid unexpired Driver's License
No, my Driver's License is currently expired
No, I don't have a Driver's License
State Driver's License or State ID number
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Professional Information
How many hours are you interested in?
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Desired Pay
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Availability (if you're applying to a non clinical position, please choose "not available")
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Morning (8am-12pm)
Afternoon (12pm-3pm)
Evening (3pm-7pm)
Not available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please check if you have the following certifications
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CPR
First Aid
Safety Care or Crisis Management TrainingI
None
Other
Professional Licenses
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Completed Education
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High School Diploma or equivalent
Associates Degree
Bachelors Degree
Graduate Degree
Post-Graduate Degree
Doctoral Degree
Other
Degrees in progress
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Past Experiences and References
Professional Experience #1
Current Employer Name
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Position and Job Duties
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Name of Supervisor and Contact Information
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Reason for leaving employment
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May we contact this employer?
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Yes
No
Professional Experience #2
Current Employer Name
Position and Job Duties
Name of Supervisor and Contact Information
Reason for leaving employment
May we contact this employer?
Yes
No
Professional Experience #3
Current Employer Name
Position and Job Duties
Name of Supervisor and Contact Information
Reason for leaving employment
May we contact this employer?
Yes
No
Professional References #1
Reference Name
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Company and Position
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Relation
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Phone Number
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Email
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example@example.com
Professional References #2
Reference Name
Company and Position
Relation
Phone Number
Please enter a valid phone number.
Email
example@example.com
Professional References #3
Reference Name
Company and Position
Relation
Phone Number
Please enter a valid phone number.
Email
example@example.com
Have you ever been convicted of a crime?
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Yes
No
If you answered "yes" to the previous question, please include details of pastconvictions (including offense, date, and place for each conviction)
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Acknowledgements
This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.
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I understand and agree
Terms and conditions
"I hereby certify that I have been informed of the duties, the hours, and days of work of the position for which I am applying and agree that I can perform the duties described, and that the information on this application is correct and complete to the best of my knowledge. I understand that any misstatement or omission of information is grounds for ending the hiring process or dismissal. I authorize verification of information provided on this application; and authorize the references listed above to give you all pertinent information concerning my previous employment; and release all parties from all liability for any damage that may result from furnishing same to Infinity ABA Therapy & Autism Services LLC"
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I understand and agree with these terms
"I authorize investigation of all statements contained in this application. I understandthat the misrepresentation or omission of facts called for is cause for dismissal at anytime without any previous notice. I hereby give the Company permission to contactschools, previous employers (unless otherwise indicated), references, and others, andhereby release the Company from any liability as a result of such contract."
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I understand and agree with this terms
All clinical positions at Infinity ABA Therapy & Autism Services LLC will require a background check in order to work with the population we serve.
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I consent to a background check
I do not consent to a background check
All clinical positions at Infinity ABA Therapy & Autism Services LLC will require a TB Screening dated within the past year in order to work with the population we serve.
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I consent and will provide results of a valid TB Screening dated within the past year
I do not consent and will not provide results of a valid TB Screening dated within the past year
Please upload copies of the following documents here: Transcripts from Highest Degree Completed, Professional License or Certifications, CPI/First Aid/BLS/CPR Certifications:
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