Chrysalis Academy Employment Application (Secure)

Full Name

First Name Last Name

Email Address *

Cell Phone Number *

Area Code Phone Number

Street Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Emergency Contact Name *

First Name Last Name

Emergency Contact Number *

Area Code Phone Number

Position Applying for *

Teaching Assistant Teacher Intern

How did you hear about us? *

ASU website Google search ASU state press Craigslist Friend Parent

Education: *

Name & Location

Graduated Yes/No

Degree or Major

High School

College

Certifications (If you have any of the following, please write the expiration date, otherwise leave blank).

Expiration

CPR-Infant, Child, Adult

First Aid

Class I Finger Print Clearance

Professional (Select one) *

Teaching Assistant RBT SLP SLPA OT Teacher None of the above

Have you ever been convicted of a criminal offense? If yes please explain: *

No

Are you legally elligible to be employed in this country? *

Yes No

Employment History (Start with most recent)

Dates Employed

Company Name

Supervisor's Name

Position/Title

Reason for leaving

Can we contact your previous employer?

Employer 1

Employer 2

Employer 3

Employer 4

Company Name *

Supervisor's Name *

Company/Supervisor's Phone Number *

Area Code Phone Number

Email *

example@example.com

Start Date of Employment *

Date

Are you still employed with this employer? *

Yes No

End Date of Employment *

Date

Job Title/Position *

Describe Your Job Duties *

Reason for Leaving *

May we contact this employer *

Yes No Yes, only after I am offered a position

Company Name *

Supervisor's Name *

Company/Supervisor's Phone Number *

Area Code Phone Number

Email *

example@example.com

Start Date of Employment *

Date

Are you still employed with this employer? *

Yes No

End Date of Employment *

Date

Job Title/Position *

Describe Your Job Duties *

Reason for Leaving *

May we contact this employer *

Yes No Yes, only after I am offered a position

Please describe familiarity with Analysis of Verbal Behavior and/or Applied Behavior Analysis (Augmentative Communication Devices, Sign Language, or PECS) *

Have you ever received any type of crisis management training? If so, what kind? *

Please describe experiences working with individuals with developmental disabilities: *

What are your expectations of employment with Chrysalis Academy? *

In addition to your application, we require three individual references. This reference request should be given to a person who has personal knowledge about your employment history, education or character. References cannot be from family members. *

I understand that part of my application requires three personal/professional references.

Personal/Professional References *

Name

Title/Relationship

Phone Number

Email

1

2

3

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time. I hereby acknowledge that, unless otherwise defined by applicable law, any employment relationship with Chrysalis Academy is of an "at will" nature, which means that the Employee may resign at any time and that Chrysalis Academy may discharge the employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless, such change is specifically acknowledged in writing b an authorized executive of Chrysalis Academy. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all the rules of Chrysalis Academy.

Please Sign Name Below: *

Clear

Move Forward with Application?

Yes No

Interview Date

Date

Interview Time

: Hour Minutes AM/PM Option

Applicant Status

1. Shadow Scheduled

References Verified By:

First Name Last Name

Employment Verified By:

First Name Last Name

Date

Time

: Hour Minutes AM/PM Option

Teacher

Application for Employment

Personal Information

Education

Previous Employer 1 (Most Recent)

Previous Employer 2 (Most Recent)

Additional Questions

References

Agreement