BT Initial Screening

Behavior Technician Application

Application & pre-employment screening. Fields marked * are required.

Company website

Personal Information

First Name *Last Name *Email Address *Phone Number *Street Address City

State ZIP Code

Position & Referral

Position Applied For How did you hear about us?

Education

Highest Level of EducationField of Study School/University Name Graduation Year

Certifications & Credentials

Are you a Registered Behavior Technician (RBT)?

Yes No

Are you CPR/First Aid Certified?

Yes No

RBT Certificate Number (if applicable) RBT Certification Expiration Date Other Certifications (please list)

Experience

Do you have previous ABA experience? Please describe:Years of experience working with children with autism or special needsDescribe your experience working with individuals on the autism spectrum:What behavioral interventions are you familiar with? (e.g., DTT, PRT, NET)

Availability

Available Start Date Desired Hours Per Week

Days Available to Work

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred Work Settings

Clinic In-Home Community School

Job Requirements *

Please confirm you meet the following requirements:

I have reliable transportation to travel to client homes and/or the clinic. I have a valid driver's license and auto insurance. I am able to lift and carry up to 50 lbs (e.g., a child if needed for safety). I can pass a criminal background check. I am authorized to work in the United States.

Professional Reference 1

Name Relationship Phone Email

Professional Reference 2

Name Relationship Phone Email

Professional Reference 3

Name Relationship Phone Email

Signature & Authorization

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from employment or termination if hired. I authorize ABA Staffing Network and its partner providers to contact my references and verify the information provided.

Electronic Signature (Type Full Name) *Date *

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