Employment Application -

Employment Application

First Name *

Middle Initial *

Last Name *

Phone *

Home, Cell, Work

Street Address *

City *

State *

Zip Code *

Email *

Preferred method of contact? *

Phone

Status Desired *

Full-time (40 hours)

Half-time (20-29 hours)

Less than half-time (<19 hours)

If seeking full-time and full-time is not available right away, are you willing to start at half-time or less than half-time, and then increase when hours become available in your area? *

Yes

Date available to start *

Desired location *

Do you have one of the following degrees? *

High School Diploma or GED

Associates Degree

Bachelors in a behavioral-science related field

Masters in a behavioral-science related field

If answer Yes to having a Bachelors or Masters Degree, Please list your Major area of study.

Please choose one of the follow to best describes your current level of supervised experience in the delivery of mental health services to children with emotional disorders? (For a list of disorders with which your experience with children could qualify, please see the employment page of behavioraldimensions.com.) *

6000+ hours of clinical experience, training, or a combination of both, in the examination or treatment of children with ASD?

4000+ hours hours of clinical experience, training, or a combination of both, in the examination or treatment of children with ASD?

2000+ hours of clinical experience, training, or a combination of both, in the examination or treatment of children with ASD?

LESS THAN 2000 hours of clinical experience, training, or a combination of both, in the examination or treatment of children with ASD?

Are there any other language, besides English that you read, write, or speak Fluently *

Yes

If "Yes" Please describe

Behavioral Dimensions provides services 7 days a week between the hours of 7:00am-7:45pm. All staff are required to be available during these times as well as on weekends to qualify for full time hours. Are there any days/times that you are not available to work? *

Yes

If you answered YES above, please list the days/times you are not available.

Which weekend day do you prefer to work? *

Saturday

Sunday

Either

Number of minutes you prefer to drive one-way to a site (The average one-way drive time is 45 minutes) *

Limitations on where you prefer to work (e.g., houses with smokers, pets, etc.)

What are your career interests? (Be specific) *

How did you hear of Behavioral Dimensions? *

BDI Employee (specify below)

Online (specify below)

Newspaper (specify below)

Other (specify below)

Facebook

Specify your answer above *

Are you 18 years of age or older? *

Yes

Are you eligible to work in the United States? *

Yes

Will you now or in the future require sponsorship for an Employment Visa (example: H-1B Visa Status and/or Permanent Resident/Green Card Status)? *

Yes

Do you have a valid driver's license? *

Yes

This job requires reliable transportation and a valid driver's license.

License information *

State, License number

Do you have reliable transportation? *

Yes

Have you previously been employed by Behavioral Dimensions? *

Yes

If you answered YES to the question above, when did you work for Behavioral Dimensions?

Have you ever been discharged or forced to resign from employment? *

Yes

If you answered YES to the question above, please explain:

Do you currently hold any of the following certifications? *

Board Certified Associate Behavior Analyst

Board Certified Behavior Analyst

I can provide documentation in these areas

None of the above

Please list the school(s) you attended, if you graduated, what your degree type is, and your major/minor. *

(Example: University of Minnesota, Graduated, Master's degree, Psychology/Philosophy)

List any volunteer or social services experience. Include the place, your position and the dates you were there.

Previous Employer (1) *

If you are completing previous employer sections, all fields MUST BE COMPLETE for consideration

May we contact this employer? *

Yes

Contact name *

Phone *

Home, Cell, Work

Address *

Street Address, City, State, Zip

Position held: *

Dates of employment: From: Month/Year to: Month/Year *

Describe job duties: *

Reason for leaving? If still employed, reason for seeking another position: *

Approximate number of hours per week (on average) you worked at this job: *

Check this box if job is human services related.

Yes

Previous Employer (2)

If you are completing previous employer sections, all fields MUST BE COMPLETE for consideration

May we contact this employer? *

Yes

Contact name

Phone

Home, Cell, Work

Address

Street Address, City, State, Zip

Position held:

Dates of employment: From: Month/Year to: Month/Year

Describe job duties:

Reason for leaving? If still employed, reason for seeking another position:

Approximate number of hours per week (on average) you worked at this job:

Check this box if job is human services related.

Yes

Previous Employer (3)

If you are completing previous employer sections, all fields MUST BE COMPLETE for consideration

May we contact this employer? *

Yes

Contact name

Phone

Home, Cell, Work

Address

Street Address, City, State, Zip

Position held:

Dates of employment: From: Month/Year to: Month/Year

Describe job duties:

Reason for leaving? If still employed, reason for seeking another position:

Approximate number of hours per week (on average) you worked at this job:

Check this box if job is human services related.

Yes

Previous Employer (4)

If you are completing previous employer sections, all fields MUST BE COMPLETE for consideration

Contact name

Phone

Home, Cell, Work

Address

Street Address, City, State, Zip

Position held:

Dates of employment: From: Month/Year to: Month/Year

Describe job duties:

Reason for leaving? If still employed, reason for seeking another position:

Approximate number of hours per week (on average) you worked at this job:

Check this box if job is human services related.

Yes

Explain any gaps in employment: (if none, enter N/A)

Include any additional information that you think may be helpful to us in considering you for employment:

I understand that if I am hired, my continued employment depends on the following conditions. By signing below, I am agreeing that I have read and understand the statement below. Print name and date:

1. A background check will be completed. Evidence of a criminal background may deem me ineligible for employment 2. An inquiry will be made of my former employers over the past five years to determine if there has been any history of sexual abuse on my part. If such a history does exist, I understand that I am ineligible to be employed. 3. I consent to and authorize Behavioral Dimensions, Inc. to investigate all of the information contained herein. I also authorize the listed employers, schools, and personal references to release any and all pertinent information to Behavioral Dimensions, Inc. (without further notice to me). I release all parties from liability of damage that may result from furnishing this information. I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts or incomplete answers in any application document may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts in any application document may be cause for my dismissal at any time without prior notice. I understand that I will need to provide my own transportation for employment purposes and that my personal auto insurance will act as the primary insurance coverage if my vehicle is in use. I understand that this is an application for employment and that no employment contract is being offered.

Employment Application

Employment Application

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