Park City Clinic

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Integrated Behavioral Technologies, Inc.

First Name:

Last Name:

Email Address:

Phone Number:

Resume:

Cover Letter:

Prior Employer's Name:

What was your ending salary/wage at the prior company?

Address 2:

***This question is FOR CHILDCARE POSITIONS ONLY AT THE K.I.D.S. Place in McLouth, Kansas***

What positions are you interested in?  Check all that apply.

Any Additional Files:

Address 1:

City:

State:

Zip Code:

Address prior to the one listed above (please state address, city, state, and zip):

Check the option for the set of pronoun you want people to refer to you as:

Are you a citizen of the United States?

This field is required if you checked "no" above.

If you are not a citizen of the United States, are you authorized to work in the U.S.? 

Have you ever worked for this company? 

If you have worked for IBT, what dates were you employed?

Have you ever been convicted of a felony?

If you have been convicted of a felony, please explain.

Do you have experience working with children and/or adolescents?

If you have experience, explain in more detail.

Education Overview - I will complete the following educational history section to the best of my ability (Y/N):

Highest Level of Degree/Certification:

Institution Name:

Start Date:

End/Graduation Date:

Degree Obtained?

Qualification Gained:

Date(s) That Qualification Gained:

Additional Institution Name (if applicable):

Start Date (of additional institution):

End/Graduation Date (of additional institution):

Degree Obtained (for additional instituation)?

Qualification Gained (for additional institution):

Date That Qualification Gained (for secondary institution):

Position Overview - I will complete the following employment history section to the best of my ability (Y/N):

Current Employer's Name:

Current Position:

Current Duties:

Start Date of Current Employer

What was your starting salary/wage at your current company?

What is your current salary/wage at your current company?

May we contact your current supervisor?

If yes, please state the name, phone number and if applicable, their email address.

Did you have an employer prior to your current position?

Prior Employer #2's Name:

Prior Position at Employer #2:

Duties of Prior Position at Employer #2:

Prior Employer #2's Address:

Start Date of Prior Employer #2

End Date of Prior Employer #2

Reason for Leaving Employer #2:

What was your starting salary/wage at the prior Employer #2?

What was your ending salary/wage at the prior Employer #2?

May we contact your previous supervisor at this Employer #2?

Did you have an employer prior to your prior position (at Employer #2)?

Prior Employer #3's Name:

Prior Position at Employer #3:

Duties of Position at Employer #3:

Prior Employer #3's Address:

Start Date of Prior Employer #3

End Date of Prior Employer #3

Reason for Leaving Employer #3:

What was your starting salary/wage at the prior Employer #3?

What was your ending salary/wage at the prior Employer #3?

May we contact your previous supervisor at prior Employer #3?

Professional References

By selecting "I Agree," you authorize Integrated Behavioral Technologies (IBT) to contact the professional references you have provided below for the purpose of evaluating your employment application. You certify that the information you have provided is accurate and that your references have given you permission to share their contact information.

Reference #1 - Full Name: 

Reference #1 - Relationship: (required)

Reference #1 - Company Name of Reference: (required)

Reference #1 - Phone number:

Reference #1 - Email Address:

Reference #2 - Full Name: 

Reference #2 - Relationship: (required)

Reference #2 - Company Name of Reference: (required)

Reference #2 - Phone number:

Reference #2 - Email Address:

Reference #3 - Full Name: 

Reference #3 - Company Name of Reference: (required)

Reference #3 - Relationship: (required)

Reference #3 - Phone number:

Reference #3 - Email Address:

IBT Application

What location are you applying for?

Do you have your BACB Certification?

 Are you currently licensed in the State of Kansas as a BCBA?

 If you do not hold BACB certification, are you enrolled in a Behavior Analytic verified course sequence?

Board-Certified Behavior Analyst (BCBA) - Consultant (Wichita, KS)