Name
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First Name
Last Name
Phone
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(###)
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Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you legally entitled to work in the U.S.?
Position or Type of Employment Desired
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Behavior Technician
Registered Behavior Technician
Board Certified Behavior Analyst
Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?
Will Accept
Shift
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College
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College
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High School Graduate or General Education (GED) Test Passed?
High School
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Have you ever been convicted of a crime (other than a moving violation) or served time?
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Special skills and additional certifications held
Employer
Most recent first
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Last Salary
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Employer
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Employer Address
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Reason for Leaving
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Employer
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Employer Address
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Name
First Name
Last Name
Phone
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Relationship and Years known
Name
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Phone
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Relationship and Years Known
Name
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Relationship and Years Known
APPLICANT’S CERTIFICATION AGREEMENT 1. I understand that I may submit a copy of my résumé or curriculum vitae (CV) and that by submitting a copy of my résumé/CV I understand that it will be used only as supporting and additional background information. A résumé/CV is not an authorized substitute for a completed employee application. 2. I understand that if I should choose to complete only a portion of the required employment application that the information submitted may not be enough information from which to base any determination on, and, as a result, my application may not receive full consideration for employment. 3. I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information. I also release Azula Behavioral Consulting, LLC from all liability that may result from making background investigations. 4. I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or any required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered. 5. I agree, if I am offered and accept a position, to conform to all existing and future workplace rules, regulations, policies, and procedures of Azula Behavioral Consulting, LLC. 6. I understand and agree that Azula Behavioral Consulting, LLC reserves the right to change any wage and hours of work, in its sole discretion, at any time as deemed necessary. 7. I understand the employment relationship will be At Will, meaning that either party can end the employment relationship at any time, and for any reason, or no reason with written notice. 8. I understand that I must submit to fingerprinting/background checks, drug testing, and/or medical testing as part of the process to determine my fitness for employment and hereby agree to submit to such testing. I authorize all persons, agencies, or other entities to release any information concerning my background or test results and hereby release from all liability any persons, agencies, or other entities supplying such information. I also release Azula Behavioral Consulting, LLC from all liability that may result from making such investigations. I understand that I must participate in fingerprinting/background checks, drug testing, prior to being offered and accepting a position with Azula Behavioral Consulting, LLC. 9. I understand that any employment offer is contingent upon my providing proof of identity and eligibility to work within the United States to conform with the provisions of the Immigration Reform and Control Act of 1986. 10. I understand that all programs developed as part of my job responsibilities and all materials that I am entitled to receiving as part of my employment are the property of Azula Behavioral Consulting, LLC and that I will not try to copy, use, publish, or replicate a program or any materials for personal use, business ventures, or with other businesses. I understand that if this occurs legal action will ensue against me for violating this term of my employment. I have read and reviewed the information contained in this employment application, as well as the above-mentioned statements of agreement. By signing this employment application, I certify that I understand all of the information requested and that I have provided information that is truthful, complete, and accurate.
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