Application for Employment

Application

" * " indicates required fields

1 Introduction
2 Personal Information
3 Education & Credentials
4 Insurance Qualification Questions
5 Employment History
6 Reference Request Form
7 Submit

Introduction

Welcome 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 *

Let's begin with the easy stuff first….

Tell us about yourself
Name *
If you do not have a middle name, add “NMN” in the field requesting that information.
Address *
Email *
MM slash DD slash YYYY
Are you a citizen of the United States? *
If, no are you authorized to work in the United States?
Which position(s) you are applying for? *
MM slash DD slash YYYY

Education & Credentials

Please 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.
Are you, or have you been, a Registered Behavior Technician? *
Are you, or have you been, a Board Certified Assistant Behavior Analyst? *
Are you a Board Certified Behavior Analyst (BCBA or BCBA-D)? *
Are you, or have you been, licensed as a Behavior Analyst in any jurisdiction? *

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)? *
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? *
Have you ever been convicted of a misdemeanor or felony? *
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? *
Have you received a citation or paid a fine as a result of a board proceeding? *
Have you surrendered, either voluntarily or otherwise, your license, certification or registration? *
Have you ever been accused of sexual misconduct or any professional impropriety? *
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? *
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? *
Max. file size: 100 MB.
Select the ages of the people you have experience providing services to: *
What populations do you have experience serving? *
Do you have experience working with social groups?
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. Applications that are submitted without a cover letter cannot be accepted. ***
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. ***
Max. file size: 100 MB.

Certification

Consent *

Reference Request Form

A 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) *

Reference 1

Reference 2

Reference 3

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.

Execution Section

Consent *

Submit

Congratulations… 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!