BECA - Behavioral Education for Children with Autism

Employment Application

Behavioral Education for Children with Autism

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:

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:

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:

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
(Note: We comply with the ADA and reasonably accommodate applicants and employees.)

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? Yes No
(Convictions for marijuana-related offenses that are more than two years old need not be listed.)

If yes, state nature of the crime(s), when and where convicted and disposition of the case.

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

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

Business/Advanced

Name:
Address:
City:
State
Zip

Yes
No

For professional positions:

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Has your license/certification ever been revoked or suspended?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: Salary Starting: Ending:

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: Salary Starting: Ending:

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: Salary Starting: Ending:

Your Position and Duties:

Reason for Leaving:

May we contact this employer for a reference? Yes No

References

List three persons not related to you who have knowledge of your work performance in the last three years.

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation: No. of Years Acquainted:

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation: No. of Years Acquainted:

First Name: Last Name: Phone Number:

No. and Street: City: State: Zip:

Occupation: No. of Years Acquainted:

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 might adversely affect my chances for employment and that the answers given by me are true and correct to 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. I also understand that all offers of employment are conditioned upon the provision of satisfactory proof of identity and legal authority to work in the U.S.

Initials:	I hereby authorize Behavioral Education for Children with Autism (“BECA”) and their assigns to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to BECA 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 BECA, my former employers and all other persons, corporations, partnerships and associations from 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 BECA. 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 cause or reason and with or without prior notice, at the option of either myself or BECA, and that no promises or representations contrary to the foregoing are binding on BECA unless made in writing and signed by me and BECA’s Executive Director and Owner. I also understand that BECA 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 and all benefit plans and programs except as prohibited by law.

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

Section 9: Verfification

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Section 10: Submit Form

Choose the branch to submit your enrollment form:

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