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Employment Application

IRegistered Behavior Technician (RBT) Job Application Form - Print this form and submit

Fill out this form if you are already an RBT or you are looking to become and RBT.  You may be eligible for a grant from our company if you qualify. You can email this form to [email protected] or mail it to:

WSI Learning Center

465 N. Richard Jackson Blvd

Panama City Beach, FL 32407

Or fax it to: 850.254.0827

Instructions: Print clearly in black or blue ink. Answer all questions. Sign and date the form.

PERSONAL INFORMATION:

First Name _____________________________

Middle Name ___________________________

Last Name _____________________________

Street Address

_______________________________________________________

City, State, Zip Code

_______________________________________________________

Phone Number

(____)___________________________________

Are you eligible to work in the United States?

Yes _______ No_______

If you are under age 18, do you have an employment/age certificates?

Yes ___ No ___

Have you been convicted of or pleaded no contest to a felony within the last five years?

Yes_______ No_______

If yes, please explain: _________________________________________

__________________________________________________________

POSITION/AVAILABILITY:

Position Applied For

________________________________________

Days/Hours Available

Monday ____
Tuesday ____
Wednesday ____
Thursday ____
Friday ____
Saturday ____
Sunday ____

Hours Available: from _______ to ______

What date are you available to start work?

________________________________________

EDUCATION:

Name and Address Of School - Degree/Diploma - Graduation Date

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Skills and Qualifications: Licenses, Skills, Training, Awards

_____________________________________________________________

_____________________________________________________________

EMPLOYMENT HISTORY:

Present Or Last Position:

Employer: _____________________________________________________

Address:______________________________________________________

Supervisor: ____________________________________________________

Phone: _______________________________

Email: ________________________________

Position Title: _________________________

From: ______________ To: ______________

Responsibilities: ____________________________________________________

__________________________________________________________

Salary: _______________

Reason for Leaving: ____________________________________________

===========

Previous Position:

Employer: _____________________________________________________

Address:______________________________________________________

Supervisor: ____________________________________________________

Phone: _______________________________

Email: ________________________________

Position Title: _________________________

From: ______________ To: ______________

Responsibilities: ___________________________________________________

__________________________________________________________

Salary: _______________

Reason for Leaving: ____________________________________________

May We Contact Your Present Employer?

Yes _____ No _____

References:

Name/Title Address Phone

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature______________________________

Date__________________________________

 

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