Employment Application

APPLICATION FOR EMPLOYMENT

Applicant Information


Last Name (as it appears on your social security card)
First Name
Middle Initial
Home Street Address
Phone Number
City
State
Zip Code
Email Address
Date of Application
Position Applying For: RBTBehavior TherapistOTCOTASpeech PathologistSLP-AssistantBilling SpecialistOffice SupportOther

Clinic Location Preferred: Fort Worth/Alliance 4537 Heritage Trace Pkwy Fort Worth, Tx 76244Southlake Clinic 2425 E. Southlake Blvd Southlake, Tx 76092

How did you hear about the position for which you are applying?

If an Employee Referral, please list their name.
Check the following options you would consider: Full-TimePart-TimeTemporary

Date Available for Work:

Specify hours and days you are available:
Have you had a criminal background screening completed within the past year? YesNo

Are you subject to any type of agreement with a current or former employer or entity that would restrict your ability to work at PediaPlex Management Company, LLC. (e.g., non-compete, non-solicitation)?: YesNo



Education & Training


School Name City and State Degree/Diploma Major Course of Study Year Graduated
High School
College
College
Graduate School
Professional License/Certification # Professional License/Certification Type Issuing Agency State Issued Expiration Date
List any equipment or software programs on which you are qualified and experienced in operating:
List any languages that you speak fluently:
Can you, after employment agreement, submit verification of your legal right to work in the United States?: YesNo
Have you been previously employed by PediaPlex Management company, LLC.?: YesNo

Are you 18 years old or over? : YesNo

Will you abide by the safety rules of this company?: YesNo

Do you have relatives currently working at PediaPlex Management Company, LLC.? : YesNo

Have you ever been convicted of, found guilty of, plead guilty to, had adjudication withheld or plead no contest to a felony or misdemeanor? *: YesNo

If Yes, give dates: From: (month/year) :

To: (month/year)

If Yes, please explain:

Employment History


CURRENT/MOST RECENT JOB

Name of Employer:
Type of Business:
Address:
City:
State:
Zip code:
Title:
Supervisor Name:
Supervisor Phone Number:
Human Resource/Payroll Phone Number:
May We Contact?: YesNo
Type of Employment:Part-TimeFull-Time
Employed From (month/year):
Employed To (month/year):
Last Salary/Hourly Rate:
Brief Description of Duties:
Reason for Leaving:

PREVIOUS EMPLOYMENT


Name of Employer:
Type of Business:
Address:
City:
State:
Zip code:
Title:
Supervisor Name:
Supervisor Phone Number:
Human Resource/Payroll Phone Number:
Type of Employment:Part-TimeFull-Time
May We Contact?: YesNo
Employed From (month/year):
Employed To (month/year):
Last Salary/Hourly Rate:
Brief Description of Duties:
Reason for Leaving:

PREVIOUS EMPLOYMENT


Name of Employer:
Type of Business:
Address:
City:
State:
Zip code:
Title:
Supervisor Name:
Supervisor Phone Number:
Human Resource/Payroll Phone Number:
Type of Employment:Part-TimeFull-Time
May We Contact?: YesNo
Employed From (month/year):
Employed To (month/year):
Last Salary/Hourly Rate:
Brief Description of Duties:
Reason for Leaving:

Business References(List three individuals, in addition to listed employment references, known to you for at least three years.)


Name Occupation/Association Telephone Email Address

Agreement (Please read the following statements carefully.)


I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsification or significant omission of information requested in this application or in the application process may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize all persons listed above (and on the accompanying resume, if any) to give PediaPlex Management Company, LLC (PediaPlex, LLC.). Any and all information concerning my previous employment and education and any pertinent information they may have, personal or otherwise, and release all parties, such persons and PediaPlex LLC., from liability for any damage that may result from furnishing same to PediaPlex.

If employed by PediaPlex, LLC, I agree to abide by the policies and procedures of PediaPlex, LLC, which include the anti-harassment policy and all other policies within the employee handbook. I further understand that my employment can be terminated, with or without cause or notice, at any time, at the discretion of PediaPlex, LLC or myself.

DRUG TESTING: I understand and agree that, subject to applicable law, I may be required to take a drug and alcohol screening test. I also understand that if I test positive for the presence of drugs or alcohol, I will be ineligible for employment with the company.

CRIMINAL BACKGROUND SCREENING: I understand and agree that, subject to applicable law, I may be required to submit my fingerprints for a criminal background screening including a sex offender registry screening. I also understand that the results of such screening will be reviewed and if found to be unacceptable for the job position and/or responsibilities, I will be ineligible for employment with the company.

Sign and Date the Form


Applicant’s Signature
Date Signed (mm/dd/yyyy)
Print Full Name
Last 4 Digits of Social Security No.