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|\n| Full Name: |  |\n| NPI Number (if applicable) |  |\n| DOB: |  |\n| SS\\#: | Place of Birth: |\n\n\n| Mailing Address: |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| City: | Zip: |  |  | State: |\n| Two Major Cross Streets: |  |  |  |  |\n| Email: |  |  |  |  |\n| Contact Number: |  |  |  |  |\n| Have you previously worked under another name(s)? |  Yes  No |  |  |  |\n| If yes, provide name: |  |  |  |  |\n| Can you provide proof of eligibility in the United states? |  |  Yes |  No |  |\n\nAvailability:  Full time Part-time How many hours do you desire to work? \\#:  \n\n| Sun. | Mon. | Tue. | Wed. | Thu. | Fri. | Sat. |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |\n| When will you be available to begin work? |  |  |  |  |  |  |\n\nEducation:  \n\n| Name and Location of\u003Cbr>School | Course of Study Major/Minor | Graduated |  |  |  | Date of Graduation |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  | | Yes | | No |  |\n|  |  | | Yes | | No |  |\n|  |  | | Yes | | No |  |\n\nAdditional Information: Please list experience, skills, and qualifications which may relate to the contracted position for which you are applying:  \n\n|  |\n| --- |\n|  |\n|  |\n\n1. Have you been convicted of a felony that would prohibit your contracted duties with Applied Behavior Analysis Institute, Inc.  Yes  No. If you have answered ‘Yes’ to this item, please attach a written explanation.  \n2. Have you ever been convicted of any law violation? Include any plea of “guilty” or “no contest”,(Exclude minor traffic violations)  Yes  No. If you answered ‘Yes’ to this item, please attach a written explanation. (A conviction will not necessarily disqualify an applicant for employment. )  \n3. Are you currently employed?  Yes  No. If yes, may we contact your current employer?  Yes  No. If you have answered ‘Yes’ to this item, please provide your employer’s contact information:  \n\n| Name of Employer: |  |\n| --- | --- |\n| Supervisor’s name: | Phone \\#: |\n\n4. Do you have any physical or mental conditions that would inhibit or restrict your ability to perform the essential functions of your job? Yes  No. If yes, would you be requesting any accommodations to aid you in the fulfilling the essential duties of your  \njob?  Yes  No. If yes, what are they?  \n5. Emergency Contact (not living with you)  \n\n| Name: | Phone \\#: |\n| --- | --- |\n\n6. Do you currently hold a professional license?  Yes  No  \n\n| Type of License | State Issued | Date Obtained | Expiration Date: |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\n7. Has the license (or any other professional license) ever been suspended, revoked, placed on probation or the subject of any disciplinary proceeding; or have you ever voluntarily surrendered your license?  Yes  No. If yes, explain:  \n\n|  |\n| --- |\n|  |\n\n8. Have you ever been forced to resign from a position you held?  Yes  No. If yes, explain:  \n\n|  |\n| --- |\n|  |\n|  |\n\nEmployment Experience:  \n\n| Company name: |  |  |\n| --- | --- | --- |\n| Company address: |  |  |\n| Date Employed: | Currently employed:  Yes |  No |\n| Position Held: | Hourly pay/ Salary: |  |\n| Name of Supervisor: | Phone \\#: |  |\n| Reason for leaving: |  |  |\n\n\n| Company name: |  |  |\n| --- | --- | --- |\n| Company address: |  |  |\n| Date Employed: | Currently employed:  Yes |  No |\n| Position Held: | Hourly pay/ Salary: |  |\n| Name of Supervisor: | Phone \\#: |  |\n| Reason for leaving: |  |  |\n\n\n| Company name: |  |  |\n| --- | --- | --- |\n| Company address: |  |  |\n| Date Employed: | Currently employed:  Yes |  No |\n| Position Held: | Hourly pay/ Salary: |  |\n| Name of Supervisor: | Phone \\#: |  |\n| Reason for leaving: |  |  |\n\nReferences:  \n\n| Name: | Specialty: |\n| --- | --- |\n| Relationship to Applicant: | Telephone: |\n| Name: | Specialty: |\n| Relationship to Applicant: | Telephone: |\n| Name: | Specialty: |\n| Relationship to Applicant: | Telephone: |\n\nApplicant’s Statement:  \nI c","cbCaigNe0zuhDAqe","https://ap.wps.com/l/cbCaigNe0zuhDAqe","pdf",250311,"English","# Applicant Information\n## Contact and Identification\n## Availability and Education\n# Eligibility and Disclosures\n## Criminal History and Current Employment\n## Health Conditions and Accommodations\n## Professional Licenses and Disciplinary History\n# Employment History and References","[{\"question\":\"What information does the Employment Application collect about the applicant?\",\"answer\":\"It collects full name, application date, position seeking, identification details, date and place of birth, contact and mailing information, and whether the applicant previously worked under other names.\"},{\"question\":\"What availability details are required?\",\"answer\":\"The form asks for availability type (full time or part-time), desired hours, weekly availability by day, and when the applicant can begin work.\"},{\"question\":\"What disclosures are requested regarding eligibility and compliance?\",\"answer\":\"It requests answers about felony convictions, other law violations, current employment and permission to contact an employer, physical or mental conditions affecting job functions and accommodations, and professional license status including any suspensions or disciplinary actions.\"}]","Employment Application - Please Print | PDF",1789917543]