Employment Application

Employment Application for HCDS

5302 S Florida Ave, Suite 202, Lakeland, FL 33813 Office: 863-937-8067 Fax: 863-607-6207 Website: www.hcds.org
Section 1: Personal Information
Full Name*

First NameLast Name
Date of Birth*
Email*
example@example.com
Address*
Phone*
Desired Hourly Rate*
Date Available to begin*

MonthDayYear
Date
Are you a citizen of the United States?*

YESNONo, but I am authorized to work in the U.S.
Have you ever been convicted of a crime?*

YESNO
If yes, explain
Section 2: Hours and Service Area
Which position are you interested in applying for?*

Behavior Technician working towards RBTRBTBCaBABCBAOffice Assistant
Do you desire*

Full Time Only (30 hours or more)Part Time Only (less than 30 hours)Either

General Availability*

	Monday	Tuesday	Wednesday	Thursday	Friday
Hours of Availability

Do you wish to be listed on our website?*

YESNOOpen and willing to do so, if desired
Section 3: Client Identifier Information

Please provide any applicable information regarding certification and identification below
Council for Affordable Quality Healthcare (C.A.Q.H.) Number
National Provider Identifier (NPI) Number
Behavior Analyst Board Certification Number
RBT Number
Original Certification Date
Expiration Date
Section 4: Education and Training
High School Name and Address*
From/To Dates*
Did you graduate?*

YESNO
Degree
College School Name and Address
From/To Dates
Did you graduate?

YESNOOther
Degree
College School Name and Address
From/To Dates
Did you graduate?

YESNOOther
Degree
Other Training
Department/School
Director
From/To Dates
Completed

YESNOOther
Section 5: References

Please list 3 professional references

Type a question*

	Full Name	Phone Number	Email address	Relationship
Professional Reference #1
Professional Reference #2
Professional Reference #3

Section 6: Previous Employment

Please list your work experience for the past 5 years, beginning with most recent. If you were self-employed, give the firm name.

Job History*

	Company Name	Phone Number	Address	Supervisor	Job Title	Starting Salary	Ending Salary	From /To Dates	Reason For Leaving
Job #1
Job #2
Job #3
Job #4

May we contact the listed supervisors above? Yes/No & Add Comments*
Please upload your resume

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Section 7: Disclosure Information

If answering "YES" to any of the questions below, please provide an explanation in the space provided at the end of this section.
Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?*

YESNO
Has there been any challenge to your licensure or certification?*

YESNO
Have any of your board certifications or eligibility ever been revoked?*

YESNO
Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?*

YESNO
Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicaid program, or in regard to other federal or state governmental health care plans or programs?*

YESNO
Have you ever had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?*

YESNO
Have you ever been convicted of, pled guilty to, or pled no contest to any felony?*

YESNO
In the past ten years have you been convicted of, pled guilty to, or pled no contest to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?*

YESNO
Do you use any chemical substances that would in any way impair or limit your ability to practice applied behavior analysis and perform the functions of your job with reasonable skill and safety?*

YESNO
Do you have any reason to believe that you would pose a risk to the safety or well being of your patients?*

YESNO
Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable*

YESNO
Explanation of any "YES" answer above (or N/A)*
Section 8: Information Release, Disclaimer, and Signature
All employees require fingerprinting and background screening. In order for the stystem to be searched or a new screening initiated by our organization, you need give us permission, by returning the ACHA privcacy document below. This screening will only be initiated if you are selected to move forward with in-person interviews.

When this process begins, we will contact you for the additional information required to initiate this Level 2 Fingerprinting and Background Check with the Department of Children and Family.

Please review, sign, & upload this ACHA privacy document.

https://ahca.myflorida.com/MCHQ/Central_Services/Background_Screening/docs/Privacy_Policy.pdf
Upload Privacy Document Here*

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In exchange for the consideration of my job application for Holladay Child Development Services, I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other HCDS practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of HCDS, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the owner of HCDS. Both the undersigned and HCDS. may end the employment relationship at any time, without specified notice or reason.
I certify that my answers are true and complete to the best of my knowledge.*

I do.
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Employment Application for HCDS

Section 1: Personal Information

Section 2: Hours and Service Area

Section 3: Client Identifier Information

Section 4: Education and Training

Section 5: References

Section 6: Previous Employment

Section 7: Disclosure Information

Section 8: Information Release, Disclaimer, and Signature