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Name

First Name

Last Name

Today's Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Preferred Schedule (Please check all that apply):

Full-Time

Part-Time

Day Shift

Evening Shift

Weekend Availability

Employment Eligibility

Are you at least 21 years of age?

Yes

No?

Are you legally authorized to work in the United States?

Yes

No

Will you now or in the future require sponsorship for employment visa status (e.g., H-1B visa status)?

Yes

No

Education

Highest Level of Education Completed or # of college credits earned:

High School or GED

College Credits

Associates Degree

Bachelors Degree

Masters

Other:

Certifications & Licenses

Do you have a current Registered Behavior Technician (RBT) License

Certified

CPR/First Aid Certification

Certified

Experience and Interest

Do you have experience working with special needs children, teens, or adults?

Yes

No

Acknowledgment

Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in Section 18-8-503, C.R.S., and, upon conviction thereof, shall be punished accordingly. I understand that, as a condition of my employment, I must fulfill all employment requirements at all times, including background checks maintaining compliance with all of Colorado Behavior Learning Group’s policies and standards.

Date

MM

DD

YYYY