RBT Job App | MG Home Care

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Application Date*
MM slash DD slash YYYY
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Position Applied for*
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Phone Number*
Email*
SSN*
Driver's License No.*
BACB Registration No.*

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Job Experience
Please list the names of your present or previous employers/contractors in chronological order with present or most recent employers/contractors listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references.
Name of Employer or Contractor*
Supervisor Name*
May we contact them?*
- Yes
- No
Address
Phone Number*
Employed from*
MM slash DD slash YYYY
Employed to*
MM slash DD slash YYYY
Job Title and Duties*
Reason for Leaving
Name of Employer or Contractor*
Supervisor Name*
May we contact them?*
- Yes
- No
Address
Phone Number*
Employed from*
MM slash DD slash YYYY
Employed to*
MM slash DD slash YYYY
Job Title and Duties*
Reason for Leaving
Please list any other experience

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Education
Please describe your educational background in the table provided below.
Please select the highest degree completed*
- High School/ GED
- College/University
- Vocational School
School Name*
Graduation Year*
School Name*
Graduation Year*
Years Completed
Degree/ Area of Study/ Training*
School Name*
Graduation Year*
Years Completed
Degree/ Area of Study/ Training*

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Business and Professional References
Please list three professional references of individuals who are not related to you.
Reference #1
Person's Name*
Relationship*
Phone Number*
Email
Reference #2
Person's Name*
Relationship*
Phone Number*
Email
Reference #3
Person's Name
Relationship
Phone Number
Email

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Emergency Contact Information
Please list two emergency contacts below.
Emergency Contact #1
Person's Name*
Relationship*
Phone*
Address
Emergency Contact #2
Person's Name*
Relationship*
Phone*
Address

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Applicant Statement and Agreement
Consent*
I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for contract work and, further, authorize the prior employers/contractors and references I have listed to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations,partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
In the event of my contracting with the Company, I understand that I am required to comply with all rules and regulations of the Company.
understand that safety is extremely important to the Company and that the Company is committed to ensuring a safe working environment.
I understand that I have a responsibility to prevent accidents and injuries by observing all safety procedures. I understand and agree to comply with federal, state, and local regulations related to safety and health.
I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employmeemployment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of
the time elapsed before discovery.
I understand that if I am selected for contract, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws may require me to complete an I-9 Form in this regard.
I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.
I understand that I am not allowed to provide two different services during the same period of time, for the same or different client(s).
I understand that I can not provide services to any person that is related to me by blood. I also understand that in the event that I do provide
services to any person related to me by blood my provider could be revoked.
I authorize MG Home Care to share personal and confidential information for supervision purposes to the BCaBA/BCBA assigned.
By checking this box I attests to the fact that I have read, understand, and agree to all of the above terms.*

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Independent Contractor Acknowledgement
Consent*
I hereby acknowledge that I am an independent contractor; therefore, I am responsible for my social security and taxes. I also acknowledge that I will receive an IRS 1099 form for the preceding year by February 1st of each year which also will be sent to the Internal Revenue Service. As an independent contractor, I am not eligible for any benefits such as vacations, disability or unemployment benefits and will not be covered by workers compensation.
By checking this box I attests to the fact that I have read, understand, and agree to all of the above terms.*

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Contractor Handbook Acknowledgement
Consent*
I acknowledge receipt of the Company’s handbook. I agree to read the handbook and to follow the guidelines and policies set forth in the handbook and any amendments to the handbook along with the other policies and procedures of the Company.

I understand that I am not being hired for any definite period of time even though my wages are paid regularly. I further understand that I am an at-will employee and my employment can be terminated at any time, with or without cause and with or without prior notice either by the Company or myself. No promises or representations have been made to me that I can be disciplined or discharged from my employment with the Company only under certain circumstances or after certain events.

I am aware that the contents of the employee handbook are presented as a matter of information and that except for the at-will provisions, the handbook can be amended at any time. I realize that nothing in this handbook is intended to infringe upon my rights under Section 7 of the National Labor Relations Act (NLRA). Additionally, I am hereby made aware that under the Defend Trade Secrets Act I may not be held criminally or civilly liable under federal or state trade secret laws if I disclose a trade secret to a government official or attorney solely for the purpose of reporting or investigating a violation of law, or in a complaint or document filed in a lawsuit, if that filing is made under seal.

I understand and agree that the handbook is for informational purposes only and is not intended to create a contract, nor is it a contract of employment or continuing employment between myself and the Company. I also understand that neither the handbook nor any policy of the Company is a guarantee or promise of employment or continuing employment. I am aware that Company policy requires employees to be hired at-will and this policy cannot be changed by any oral modifications. My at-will employment status with the Company has been fully explained and I have been given an opportunity to ask questions regarding Company policies and my at-will employment status.
By checking this box I attests to the fact that I have read, understand, and agree to all of the above terms.*

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Behavior Analysis Policies and Procedures Acknowledgement
Consent*
I acknowledge that I have received a copy of the latest version of MG Home Care Services’ Policies and Procedures. In addition to this document, I agree to read and refer to the Employee Manual (not applicable for Ind. Contractors) and/or the Code for Ethical Standards for future reference and will observe present and future company policies and rules. I understand this document is not a contract of employment.

I hereby certify that I understand the abovementioned Policies and Procedures and further understand that these Policies and Procedures may be subject to change at the discretion of MG Home Care Services’ Management.
By checking this box I attests to the fact that I have read, understand, and agree to all of the above terms.*

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RBT Job Description Acknowledgement
Consent*
MINIMUM QUALIFICATION:
• Must have the Registered Behavior Technician (RBT) certification from the BACB®.
• Must have a valid driver’s license
• Must have all in-services up to date

RESPONSIBILITIES:
• Direct implementation of behavior-analytic services in one-on-one and/or group settings.
• Collect and record data based on client behaviors.
• Assist with individualized and functional assessment procedures.
• Implement behavior reduction and skill acquisition procedures as stated in the Implementation Plan.
• Generate objective session notes for service verification by describing what occurred during the sessions, in accordance with applicable legal, regulatory, and workplace requirements.
• Describe behavior and environment in observable and measurable terms.
• Comply with RBT Supervision Requirements as requested by the BACB®.
• Comply with applicable legal, regulatory, and workplace data collection, storage, transportation, and documentation requirements.
• Communicate with family, caregivers, and other professionals as authorized.
• Maintain professional boundaries and client dignity.
By checking this box I am agreeing upon fulfilling the expectations of my job as written in but not limited to this description of the RBT position. I understand that the above statements may not describe the full nature of the position but are intended to describe the general nature and level of qualifications and skills required for the position. I will work to my fullest potential to satisfy the requirements of this position and understand that if I fail to meet any aspects of these job requirements, disciplinary action may result up to and including termination from the agency.*

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Signature*
Initials*

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RBT – Job Application

Step 1 of 13

Job Experience

Education

Business and Professional References

Reference #1

Reference #2

Reference #3

Emergency Contact Information

Emergency Contact #1

Emergency Contact #2

General Information

Applicant Statement and Agreement

Availability Questionnaire

Independent Contractor Acknowledgement

Contractor Handbook Acknowledgement

Behavior Analysis Policies and Procedures Acknowledgement

RBT Job Description Acknowledgement