Employment Application

Employment Application for Rooted ABA

5302 S Florida Ave, Suite 202, Lakeland, FL 33813 Office: 863-937-8067 Fax: 863-607-6207 Website: www.rootedaba.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
YESNONo, but I am authorized to work in the U.S.
YESNO
If yes, explain
Section 2: Hours and Service Area
Behavior Technician working towards RBTRBTBCaBABCBAOffice Assistant
Full Time Only (30 hours or more)Part Time Only (less than 30 hours)Either

General Availability*

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Hours of Availability

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*
YESNO
Degree
College School Name and Address
From/To Dates
YESNOOther
Degree
College School Name and Address
From/To Dates
YESNOOther
Degree
Other Training
Department/School
Director
From/To Dates
YESNOOther
Section 5: References

Please list 3 professional references

Type a question*

Rows	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*

Rows	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.
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
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
YESNO
YESNO
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*

Cancelof
In exchange for the consideration of my job application for Rooted ABA, 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 Rooted ABA practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Rooted ABA, 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 Rooted ABA. Both the undersigned and Rooted ABA may end the employment relationship at any time, without specified notice or reason.
I do.
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Employment Application for Rooted ABA

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