Date
Position Applying For Desired hours per week
Name E-Mail Address
Address City
State Zip
Telephone Alt Telephone

Please enter your availability in the table below. Indicate both start and end times.
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Note: Employment here may require occasional or regular weekend shifts


What is the earliest possible date you would be available to work?
Are you seeking temporary employment? Yes No If yes, indicate end date
Do you have reliable transportation? Yes No If yes, please indicate primary type: Car Busline
Please indicate distance you are willing to travel to and from work (i.e., distance, time and/or cities).
Please list any allergies which would affect you working in a household. Dogs Cats Smoking Other (please list)

Education:
School Major Dates Attended Certificate/Degree Completion Date
ABA Training/Experience: Yes No
Please list all supervisors you have worked with performing ABA:
Why are you interested in this position?
What do you feel most qualifies you?
Are you taking this position for college credit? Yes No If yes, what Professor?
Did someone refer you to this position? Yes No If yes, referred by
Work Experience:
Employer Job Title Dates Worked Salary Reason for Leaving
Please indicate any employer you do not want contacted
Volunteer (or unpaid) experience:
Institution Type of Work Total Hours
Special skills or talents (CPR, sign language, etc.)
Please list if you are fluent in any language besides English.
Professional References (supervisor from previous work experience or a teacher--not a co-worker)
Name and Address Title Phone Number
Have you ever been convicted of an offense other than minor traffic violations? Yes No
If YES, please list the details below. Also list any pending criminal charges, including date, location, charge, court and disposition of case.

Neither convictions nor pending charges are an automatic bar to employment. Each case is considered on its own merit, and as it may substantially relate to the position for which you are applying.
This job may require the lifting/carrying of small children across the room or up/down the stairs.
Are you able to lift/transport a 30 to 50 pound child? Yes No
If No, please explain:
I hereby declare the information provided by me in this application for employment is true, correct and complete to the best of my knowledge. I understand that, if employed, any mis-statement or omission of fact on this application shall be considered cause for dismissal. I hereby authorize ATC to verify any information by contacting former employers, unless otherwise stipulated. I also consent to a criminal background check conducted by ATC for $16.00, which will be deducted from my first paycheck in the event of employment.


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