Hiring Documents Application

BDS Application

Address(Required)
MM slash DD slash YYYY
Are you a citizen of the United States?(Required)
If, no are you authorized to work in the United States?
Untitled(Required)
MM slash DD slash YYYY

Education

Please provide information about each level of school you have completed, or are currently engaged in.
Are you a Board Certified Behavior Analyst?(Required)
Are you, or have you been, licensed as a Behavior Analyst in any jurisdiction?(Required)
Are you, or have you been, a Board Certified Assistant Behavior Analyst?(Required)
Are you, or have you been, a Registered Behavior Technician?(Required)

Insurance Qualification Questions

Have 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)?(Required)
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?(Required)
Have you ever been convicted of a misdemeanor or felony?(Required)
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?(Required)
Have you received a citation or paid a fine as a result of a board proceeding?(Required)
Have you surrendered, either voluntarily or otherwise, your license, certification or registration?(Required)
Have you ever been accused of sexual misconduct or any professional impropriety?(Required)
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?(Required)
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?(Required)
Max. file size: 100 MB.
Select the ages of the people you have experience providing services to:(Required)
What populations do you have experience providing services to?(Required)
Do you have experience working with social groups?(Required)
If yes, what group sizes do you have experience providing services to?

Employment History

Please 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. ***
Max. file size: 100 MB.
Max. file size: 100 MB.

Certification

I 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.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.





Breakthrough Developmental Services (BDS) is an equal opportunity employer that is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion. Your application will be considered without regard to regard to ethnicity, age, color, gender identification, gender expression, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation, or physical or mental disability. All BDS employees have a responsibility to treat others with dignity and respect at all times.