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Employment Application

Thank you for your interest in employment with BECA. Please fill out the information below. BECA is an equal opportunity employer.

 

About You

Date: Last Name: First Name: Middle Initial:

Email Address:

Present Address:

No. and Street: City: State: Zip:

Permanent Address (If different from Present Address):

No. and Street: City: State: Zip:

Business Phone: Home Phone:

Employment Desired

Position Applying For:

Are you applying for:
Regular full-time work? Yes No
Regular part-time work? Yes No
Temporary work, e.g., summer or holiday work? Yes No

If applying for temporary work, during what period of time will you be available?

Are you available for work on weekends? Yes No

Would you be available to work overtime, if necessary? Yes No

Personal Information

Have you ever applied to or worked for or with BECA before? Yes No

If yes, when:

Do you have any friends or relatives working for or with the BECA? Yes No

If yes, state name and relationship:

Name: Relationship:

Name: Relationship:

If hired, would you have a reliable means of transportation to and from work? Yes No

Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.) Yes No

If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country? Yes No

Can you perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? Yes No
If no, describe the functions that cannot be performed.

(Note: We comply with the ADA and consider reasonable accomodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Are you currently employed? Yes No

If so, may we contact your current employer? Yes No

Education, Training and Experience

SCHOOL NAME AND ADDRESS NO. OF YEARS
COMPLETED
DID YOU
GRADUATE?
DEGREE/
DIPLOMA
         
High School
Name:
Address:
City:
State
Zip
Yes
No
         
         
College/University
Name:
Address:
City:
State
Zip
Yes
No
         
         
Vocational/Business
Name:
Address:
City:
State
Zip
Yes
No
         
Health Care Training
Name:
Address:
City:
State
Zip
Yes
No

Option: Some of our clients may not speak English. Do you speak, write or understand any foreign languages? Yes No

Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at BECA? Yes No
If so, please explain:

Answer the following questions if you are applying for a professional position:

Are you licensed/certified for the position for which you are applying? Yes No

Name, number and issuing state of license/certification:

Has your license/certification ever been revoked or suspended? Yes No

If yes, state reason(s), date of revocation or suspension and date of reinstatement:

Employment History

List below all present and past employment starting with your most recent employer (last five years is sufficient). You must complete this section even if attaching a resume.

Name of Employer: Telephone Number:

Type of Business: Your Supervisor's Name:

No. and Street: City: State: Zip:

Dates of Employment From: To:

Your Position and Duties:

Reason for Leaving::

May we contact this employer for a reference? Yes No

Name of Employer: Telephone Number:

Type of Business: Your Supervisor's Name:

No. and Street: City: State: Zip:

Dates of Employment From: To:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference? Yes No

Name of Employer: Telephone Number:

Type of Business: Your Supervisor's Name:

No. and Street: City: State: Zip:

Dates of Employment From: To:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference? Yes No

Military Service

Have you obtained any special skills or abilities as the result of service in the military? Yes No

If so, describe:

References

List below three previous supervisors (persons not related to you) who have knowledge of your work performance within the last three years.

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation & Company: No. of Years Acquainted:

Relation (supervisor, personal, etc)

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation & Company: No. of Years Acquainted:

Relation (supervisor, personal, etc)

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation & Company: No. of Years Acquainted:

Relation (supervisor, personal, etc)

Signature and Verification

Please read carefully, initial each paragraph and digitally sign below.

Initials: I hereby certify that I have not knowingly withheld any information that mightadversely affect my chances for employment and that the answers given by me are true and correctto the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
   
Initials: I hereby authorize Behavioral Education for Children with Autism and their assignsto thoroughly investigate my references, work record, education and other matters relatedto my suitability for employment and, further, authorize the references I have listed todisclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associationsfrom any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
   
Initials: I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are bindingon the company unless made in writing and signed by me and the Company's designated representative. I also understand that Behavioral Education for Children with Autism retains the sole and exclusive right at any time, with or without cause or advance notice, to change or eliminate all policies, practices and terms and conditions of my employment andall benefit plans and programs except as prohibited by law.
   
Initials: Should a search of public records (including records documenting an arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment) be conducted byinternal personnel employed by the Company, I am entitled to copies of any such public records obtained by the Company unless I mark the check box below. If I am not hired as a result of such information, I am entitled to a copy of any such records even though I have initlaied the box to the left.
   
Initials: I waive receipt of a copy of any public record described in the paragraph above.

Date: Digital Signature (Please type in your name):

Section 9: Verfification

Please type in the number fourteen for verification

Section 10: Submit Form

 

Choose the branch to submit your enrollment form:

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