RBT’S JOB APPLICATION Step 1 of 7 - Applicant Statement and Agreement 14% This field is hidden when viewing the formDate(Required) This field is hidden when viewing the formPosition(Required)Please read the paragraph below. If there is anything that you do not understand, please ask. 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. I 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 employment 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 the 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 who 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. Consent(Required) I attest to the fact that I have read, understand, and agree to all of the above terms. Name(Required) First Middle Last DOB(Required) Phone(Required)Email(Required) SSN(Required)Driver License NumberBoard Certification NumberNPIMedicaid Provider No (Provider ID)Medicaid Expiration Date Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Have you ever used another name?(Required) Yes No 2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?(Required) Yes No 2a. Please explain(Required)3. Have you ever worked for this company before?(Required) Yes No 3a. If yes, please give dates and position(Required)4. Do you have friends and/or relatives working for this company?(Required) Yes No 4a. Please enter name and relationships.(Required)5. On what date are you available to begin to work?(Required) 6. If hired, would you have a reliable means of transportation to and from work?(Required) Yes No 7. Can you travel if the position requires it?(Required) Yes No 8. If contracted, can you present evidence of your identity and legal right to work in this country?(Required) Yes No Emergency Contact #1Name(Required) First Last Relationship(Required)Phone(Required)Email Emergency Contact #2Name(Required) First Last Relationship(Required)Phone(Required)Email Have you ever been involuntarily terminated or asked to resign from any job?(Required) Yes No Please explain(Required)Please explain any gaps in your employment history.Please list any other experience, job related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment. Please list the names of your present or previous employers/contractors in chronological order, with the most recent employers/contractors listed first. Be sure to account for all periods of time. If self-employed, give the firm name and supply business references.Employer #1Name of EmployerSupervisor's NamePhoneMay we contact them? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates Employed (From) Dates Employed (To) Job Title and DutiesReason for LeavingEmployer #2Name of EmployerSupervisor's NamePhoneMay we contact them? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dates Employed (From) Dates Employed (To) Job Title and DutiesReason for Leaving Independent Contract AgreementRBT JOB DESCRIPTION REPORTS TO: BCBA/BCaBA MINIMUM QUALIFICATIONS: 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. Consent(Required) By clicking here, 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.Please visit the following link to read the latest version of MG Home Care's Independent Contractor Agreement. Consent(Required) I’ve read this agreement carefully and understand its terms and conditions.Consent(Required) I 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 Paid Time Off, disability or unemployment benefits.Please visit the following link to read the latest version of MG Home Care's Confidentiality and Non-disclosure Policy.Consent(Required) By clicking this link I agree that I've read this agreement.Initials(Required)Signature(Required)Your NameYour NameYour NameYour Name
