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Name(Required) First Middle Last Today's Date(Required) MM slash DD slash YYYY Email Address(Required) Phone(Required)Current Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican 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 Office Applying To(Required)JeffersonvilleEvansvilleLouisville EastLouisville SouthNew AlbanyWest IndyBowling GreenPosition Applying For(Required) Desired Pay(Required) Availability(Required) Full Time/Part Time(Required) Full Time Part Time Are you a US Citizen, or do you have the legal right to remain and work permanently in the US?(Required) Yes No Do you have adequate means of transportation to get to and from work each day?(Required) Yes No License(s) You Currently Have (check all that apply)(Required) Registered Behavior Technician CPR Certified First Aid Certified Crisis Prevention BCBA License # – Registered Behavior Technician(Required) License Expiration Date – Registered Behavior Technician(Required) MM slash DD slash YYYY License # – CPR Certified(Required) License Expiration Date – CPR Certified(Required) MM slash DD slash YYYY License # – First Aid Certified(Required) License Expiration Date – First Aid Certified(Required) MM slash DD slash YYYY License # – Crisis Prevention(Required) License Expiration Date – Crisis Prevention(Required) MM slash DD slash YYYY License # – BCBA(Required) License Expiration Date – BCBA(Required) MM slash DD slash YYYY Have you ever had any professional certification/license revoked, suspended, limited, or not renewed in any state?(Required) Yes No Have you every been convicted of a crime?(Required) Yes No Please describe crime(s) in full. (Note: Conviction of a crime will not necessarily preclude your employment)(Required)Record of EducationName of High School(Required) High School Graduation Date(Required) Month Day Year Name of College(s)(Required) College Major(Required) College Graduation Date(Required) Month Day Year College Degree(Required) List Other Education: Include school name, major, graduation date and degree(Required)Employment RecordAre you currently employed?(Required) Yes No Current Employer's Name(Required) Current Employment Start Date(Required) MM slash DD slash YYYY Current Employment Position(Required) Current Employment Starting Pay(Required) Current Employment Ending Pay(Required) Reason for Seeking Other Employment(Required)Previous Employer's Name(Required) Previous Employment Start Date(Required) MM slash DD slash YYYY Previous Employment End Date(Required) MM slash DD slash YYYY Previous Employment Position(Required) Previous Employment Starting Pay(Required) Previous Employment Ending Pay(Required) Reason for Leaving Previous Employer(Required)Do you have other work history?(Required) Yes No Previous Employer's Name (2)(Required) Previous Employment Start Date (2)(Required) MM slash DD slash YYYY Previous Employment End Date (2)(Required) MM slash DD slash YYYY Previous Employment Position (2)(Required) Previous Employment Starting Pay (2)(Required) Previous Employment Ending Pay (2)(Required) Reason for Leaving Previous Employer (2)(Required)Do you have any additional work history?(Required) Yes No Additional Work History: List company name, employment start and end date, start and end pay, and reason for leaving(Required)**Adapt For Life provides equal employment opportunities without regard to race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability. I certify that the information in this application is true and complete for all practical purposes. Should a position be offered and later it is found that any of this information is untrue, incomplete, or misrepresented, I understand and agree that the Adapt For Life has the right to end my employment. I voluntarily give Adapt For Life the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within 3 days show satisfactory evidence of identity and eligibility for employment.Applicant Signature(Required) Δ
