Please enter your availability in the table below. Indicate both start and end times.
Note: Employment here may require occasional or regular weekend shifts
Yes No If yes, indicate end date
Yes No If yes, indicate type: Car Busline
Dogs Cats Smoking Other (please list)
Education
School:
Major:
Dates Attended:
Degree Received:
If No, Anticipated Completion Date:
School:
Major:
Dates Attended:
Degree Received:
If No, Anticipated Completion Date:
School:
Major:
Dates Attended:
Degree Received:
If No, Anticipated Completion Date:
Yes No
Please list all supervisors you have worked with performing ABA:
Yes No If yes, what Professor?
Yes No If yes, referred by
Work Experience
Employer: Job Title: Dates Worked: Salary: Reason for Leaving:
Employer: Job Title: Dates Worked: Salary: Reason for Leaving:
Employer: Job Title: Dates Worked: Salary: Reason for Leaving:
Employer: Job Title: Dates Worked: Salary: Reason for Leaving:
Volunteer (or unpaid) experience:
Institution: Type of Work: Total Hours:
Institution: Type of Work: Total Hours:
Professional References (supervisor from previous work experience or a teacher--not a co-worker)
Name and Address: Title: Phone Number: Email:
Name and Address: Title: Phone Number: Email:
Name and Address: Title: Phone Number: Email:

Our company is an Affirmative Action/Equal Employment Employer and as such, we are required to collect and maintain information related to applicants in order to meet governmental recordkeeping and reporting requirements and to monitor the effectiveness of our outreach, recruitment and other employment practices.

At this time, we are asking you to help us meet our obligations by providing the information listed on the following pages. Please note that the information will be used only in accordance with the provisions of applicable laws, executive orders, and regulations. Providing this information is voluntary and refusal to so will not result in any adverse treatment. The information you provide will be held in strict confidence except that:

  1. Necessary management and supervisory personnel may be informed to ensure proper placement and to provide reasonable job accommodations;
  2. First aid and safety personnel may be informed to the extent appropriate, if the condition might require emergency treatment; and
  3. Government officials investigating affirmative action program compliance may have access to reported information.

Thank you for your cooperation in this important initiative.

Autism Treatment for Children abides by the requirements of federal laws which prohibit discrimination and require affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified individuals with the following legally protected status: race, color, religion, sex, national origin (per Executive Order 11246), disability (per 41 CFR 60-741.5(a), and protected veterans (per 41 CFR 60-300.5(a).

Company website   Job board   Newspaper   Temp agency   Search firm   Educational institution   Walk-in   Employee referral   College Recruiting   Professional Association   State employment agency   Other:
Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)
Not Hispanic or Latino (if not Hispanic or Latino, please address race below)
I choose not to disclose this information

 Do not respond if you selected Hispanic or Latino above

White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
American Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five races
I choose not to disclose this information

Protected Veterans

The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran

Disabled Veteran

A “disabled veteran” is one of the following:

A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

A person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
Active Duty Wartime or Campaign Badge Veteran An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

Recently Separated Veteran

A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

Active Duty Wartime or Campaign Badge Veteran

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

Armed Forces Service Medal Veteran

An “armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

I am a Protected Veteran
I am not a Protected Veteran
I choose not to disclose the information

 

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 $15.00, which will be deducted from my first paycheck in the event of employment.
 
ATC conducts all employment practices including recruitment and hiring in accordance with Equal Opportunity Employment law and adheres to an Affirmative Action plan in all employment practices including recruitment and hiring to ensure equal opportunity to women, racial or ethnic minorities, persons with disabilities and any other protected groups.