Momentum Behavioral Services, LLC

For the Position of Behavior Technician Date:______
Please return to

Momentum Behavioral Services, LLC

Employment Application

Name:______

Last First

Address: ______

StreetCity StateZip

Cell Phone: Email address:

Emergency Contact:

Availability: (Check all that apply)
Full-time Part-time
Days and Times Available:
M______T______W______TH______F______Sa______
How many hours per week are you looking for?
If hired, on what day can you start?
What is your expected rate of hourly pay?

How many years of ABA experience do you have?

Please list your experience with ABA strategies, the settings you have implemented ABA services (home, center, school) and the BCBA that you were supervised by:

Have you ever been employed by Momentum Behavioral Services, LLC ? If yes, please indicate when and the name of your former supervisor and reason for leaving. / Yes / No / Do you have any relatives or friends working at Momentum Behavioral Services, LLC? If yes, please list names and relationship. / Yes / No
If hired, would you have a reliable means of transportation to and from work? / Yes / No / If hired, are you able to provide documentation required by U.S. Citizenship and Immigration Services to verify your right to work in the United States? / Yes / No
Are you at least 18 years of age? / Yes / No / Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? If No, describe the job related functions that cannot be performed:
(Note: we comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Please advise us if any accommodation is needed to participate in the application process). / Yes / No
If hired for the school year, can you commit to at least 1 year? / Yes / No / If hired for summer, can you commit to the full 7 weeks? / Yes / No
Momentum is a smoke, drug, and gun free workplace. Are you willing and able to comply with this? / Yes / No / Have you ever been convicted of any offense other than a minor traffic violation?
If Yes, state the nature of the crime(s), when and where convicted and disposition of the case. / Yes / No
Education: Circle or highlight highest level of education completed:
High School Undergraduate Graduate Doctoral
School / Location / Degree Received / Major

Certification/Licensure

Mark or highlight the following certifications that you have in good standing:

□CBT include certification number:

□RBT include certification number:

□ 1st Aide/ CPR □ HIV/AIDS Training

□Right Response or other physical management or de-escalation behavior training

Name of Certification/License / Location / Expiration Date / Certification/License Number

Skills/Language: List any special skills or languages which you feel make you suited for this position:

Work History:Please attach resume with all work experience. If there is anything that is not included on your resume, please list below. Also list any specialized experience that you have in teaching academic, social, or sport skills that we may be utilized for teaching the clients.

______

Is there a certain population or age range that you are most interested in and/or would like to gain more experience working with?

______

References: List below 3 persons not related to yourself who have knowledge of your work performance and/or character.Please include one recent academic or practicum supervisor if applicable.

Name / Title:
Address / City: State:
Relationship / Phone:
Name / Title:
Address / City: State:
Relationship / Phone:
Name / Title:
Address / City: State:
Relationship / Phone:

How did you hear about Momentum and why are you interested in working for Momentum Behavioral Services, LLC? Did anyone refer you?

______.

Please read carefully, initial each paragraph and sign below.

___ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any documentation used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

___I hereby authorize Momentum Behavioral Services, LLC to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the Company any and all letters, reports and other information related to my work and/or school records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other such persons from any and all claims, demands or liabilities arising out of or in any way related to such investigation.

___I understand that nothing contained in the application, or conveyed during any interview, or during any employment if hired, is intended to create an employment contract between myself and the Company. Momentum Behavioral Services is an At Will employer.

___I understand Momentum Behavioral Services, LLC has a drug free workplace and I agree to comply with this condition of employment.

Applicant Signature:______Date:______

Momentum Behavioral Services, LLC is an equal opportunity employer and does not discriminate.

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