Application for Employment Application "*" indicates required fields 1Introduction2Personal Information 3Education & Credentials4Insurance Qualification Questions5Employment History6Reference Request Form7Submit IntroductionWelcome to the Breakthrough Developmental Services application and hiring process. We are excited that you have decided that this may be an organization that you would like to work with. Please complete the combined application to continue with the hiring process. Please be advised that the questions presented in this form represents information requested from organizations that we contract with as well as our company policies. Failure to complete this application in its entirety, may result in your rejection. Thank you, The Human Resources Department* Yes, I would like to begin the hiring process!Please be advised that the questions presented in this form represents information requested from organizations that we contract with as well as our company policies. Failure to complete this application in its entirety, may result in your rejection. Thank you, The Human Resources Department Let's begin with the easy stuff first….Tell us about yourselfName* First Middle Last If you do not have a middle name, add “NMN” in the field requesting that information.What are your pronouns? Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Enter Email Confirm Email Date of Birth* MM slash DD slash YYYY Social Security Number*Are you a citizen of the United States?* No Yes If, no are you authorized to work in the United States? No Yes Which position(s) you are applying for?* Accreditation & Evaluation Manager Administrative/Office Assistant Behavior Technician/Behavior Support Staff (RBT or BCaBA) Board Certified Behavior Analyst (BCBA or BCBA-D) Human Resources Admin Intern Occupational Therapist Speech Language Pathologist If hired, when are you available to start training/working?* MM slash DD slash YYYY Education & CredentialsPlease provide information about each level of school you have completed, or are currently engaged in. If you have not completed the levels presented, leave those fields blank.High School or GED: Provide the name of the school along with the year you graduated, the city, and state it is located in. If the school was outside of the United States, provide the country as well*Vocational and/or Undergraduate school(s) – Provide the name of the school, the city, and state, the dates you attended (month/year format), and your course of study for each school you attended. If you obtained your degree, note the full title of the degree and when it was conferred.*Graduate and/or Post Graduate school(s)- Provide the name of the school, the city and state, the dates you attended (month/year format), and your course of study for each school you attended. If you obtained your degree, note the full title of the degree and when it was conferred.*Are you, or have you been, a Registered Behavior Technician?* No, I have never been an RBT I was an RBT, but my license has expired Yes, I am an RBT If you are, or were an RBT, what is/was your Credential Number? Are you, or have you been, a Board Certified Assistant Behavior Analyst?* No Yes If yes, what is/was your Certification Number? Are you a Board Certified Behavior Analyst (BCBA or BCBA-D)?* No Yes If yes, what is your Certification Number? Are you, or have you been, licensed as a Behavior Analyst in any jurisdiction?* No Yes If yes, where? Please provide locations and dates of licensure. Insurance Qualification QuestionsHave you ever been refused coverage for professional liability or malpractice insurance or has your malpractice or professional liability insurance ever been canceled or declined for renewal (non-renewed)?* No Yes Has any claim or suit ever been brought against you for alleged malpractice or professional liability, or are you aware of ay incident or existing circumstance that might reasonably lead to a claim or suit?* No Yes Have you ever been convicted of a misdemeanor or felony?* No Yes Have you ever had your license, certification or registration suspended, revoked, or placed on probation by a licensing board, board of examiners, or any other governmental entity that regulates your profession?* No Yes Have you received a citation or paid a fine as a result of a board proceeding?* No Yes Have you surrendered, either voluntarily or otherwise, your license, certification or registration?* No Yes Have you ever been accused of sexual misconduct or any professional impropriety?* No Yes Have any complaints ever been filed against you or have there ever been any formal or informal investigations or inquiries opened with a peer review committee or an ethics committee of a professional association, hospital, health care facility, or any other governmental or private entity?* No Yes Do you know of any reason why you cannot comply with the legal, ethical, or professional standards set by law, by regulation, by a peer review committee or by an applicable code of ethics in any jurisdiction where you provide services?* No Yes If your answer to any of the previous questions is “yes”, please provide a detailed explanation below. Please also provide any pertaining documentation (i.e. Dismissal Letters, Consent Agreements, etc…). In addition, if you have previously reported this on prior applications, or it is already on file with our agency, please indicate so.FileMax. file size: 100 MB.Select the ages of the people you have experience providing services to:* Early childhood (ages 0 – 5) Children (ages 5 – 10) Adolescents (ages 10 – 18) Young Adults (ages 18 – 35) Adults (ages 35 – 65) Seniors (ages 65+) None of the above What populations do you have experience serving?* Developmental disabilities Intellectual disabilities Learning disabilities Typically developing None of the above Do you have experience working with social groups? No Yes If yes, what group sizes do you have experience providing services to? 2 or 3:1 4 or 5:1 I have experience with larger groups Employment HistoryPlease upload a list of your total employment history. Your current, or most recent, employment should be listed first. Please list all jobs (including self- employment and military service) that you have held and explain any gaps in employment. For each entry include the name of the employer, the employer’s address, the employer’s telephone number, your supervisor’s name, your job title, your dates of employment (in month/year format), and your reason for leaving. *** Due to the terms of the contracts we have signed with our payers, you must include a cover letter for all positions within our organization. Applications that are submitted without a cover letter cannot be accepted. *** Cover Letter*Max. file size: 100 MB.*** Due to the terms of the contracts we have signed with our payers, you must include a cover letter for all positions within our organization. Applications that are submitted without a cover letter cannot be accepted. ***File – Resumé or C.V*Max. file size: 100 MB.Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current or previous employer:CertificationConsent* I agree to the information belowI certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize Breakthrough Developmental Services, LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the organization by its President, the employment relationship will be “at-will.” In other words, the relationship will be entirely voluntary in nature, and either I, or my employer, will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I will have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Breakthrough Developmental Services, LLC, except in a specific written contract of employment signed on behalf of the organization by its President, has the power to alter or vary the voluntary nature of the employment relationship. Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. By typing your signature below, you affirm that you have read and agree with the above statement. Reference Request FormA MESSAGE FROM THE HUMAN RESOURCES DEPARTMENT: Please be advised that we will not schedule your interview until we have collected the information from your 3 professional references. It is recommended that you double check the contact information that you are providing for your references as incorrect information will cause delays in us being able to connect with your references. Make sure that you INCLUDE ALL REQUESTED INFORMATION for your references. If you do not include this information, we will not be able to contact your references. If you do not hear back from us within ONE WEEK of submitting this document, check with your references to ensure they have completed their portion of the reference material prior to contacting us at [email protected], or 855-255-5270. Thank you!Right to Access (Pick one)* I voluntarily give up my right, or privilege, to inspect or challenge the content and comments expresses in the reference. I retain my right, or privilege, to inspect or challenge the content and comments expresses in the reference. Reference 1Name* Email Address* Phone Number*Reference 2Name* Email Address* Phone Number*Reference 3Name* Email Address* Phone Number*Reference 4 (Optional)While one 3 references are required, you have the option to submit a 4th person. We will take the first 3 that we are able to connect with. Name Email Address Phone NumberExecution SectionConsent* I agree to the statement below.I hereby provide my permission for Breakthrough Developmental Services, or their appointed representative, to contact the references that I have provided above. I hereby certify that the information provided on this form is true and accurate to the best of my knowledge. I also acknowledge that providing knowingly false or inaccurate information on this form will be cause for dismissal if I am hired. *** Typing your full name in the box below shall serve as your written signature for this document.*** Please provide the last 4 digits of your Social Security Number in the box below. SubmitCongratulations… Once you click submit below, you will receive a confirmation message. If you have submitted for a clinical behavior support position (RBT, BCaBA, or BCBA), please complete the appropriate Affirmation. Thank you! Δ
