1. Application for Employment
PERSONAL DETAILS:
Name: _____________________________________________________ Date of Birth: ___________________
Street Address: _____________________________________________________________________________
City:__________________________________________ State: _____________ ZIP: ____________________
Ph: _________________________ E-mail: ______________________________________________________
Driver’s License #/State: __________________________________ SS #:______________________________
Do you own or have the use of a car? ☐Y ☐N
Are you legally authorized to work in this country? ☐Y ☐N
Have you ever been convicted of a felony? ☐Y ☐N
If yes, please explain (all information is confidential):
__________________________________________________________________________________________
__________________________________________________________________________________________
We must perform a criminal background check on you, and check your name against the Illinois and National
Sex Offender Registry in addition to the Illinois State Policy Murderer and Violent Offender Against Youth
Registry before hiring you. Are you willing to undergo these checks? ☐Y ☐N
CURRENT & PREVIOUS EMPLOYMENT:
Please provide details about your current and previous occupations. (Continue on a separate sheet if necessary).
Please provide approximate starting and finishing dates and reasons for leaving.
Current Employment:
Company: ___________________________________ Position Held: _________________________________
Street Address: _____________________________________________________________________________
City: ______________________________State: _____ ZIP: ____________ Ph: _________________________
Dates of Employment: From ________________ to ________________ Rate of Pay: _____________________
Name and Title of your immediate supervisor: ____________________________________________________
May we contact him/her? ☐Y ☐N
Duties & Responsibilities:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________________
2353 Hassell Road, Suite 110, Hoffman Estates, IL 60169
ph: 847.884.7030 www.cepautism.org

2. Application for Employment
Reason for Leaving:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Previous Employment:
Company: ___________________________________ Position Held: _________________________________
Street Address: _____________________________________________________________________________
City: ______________________________State: _____ ZIP: ____________ Ph: _________________________
Dates of Employment: From ________________ to ________________ Rate of Pay: _____________________
Name and Title of your immediate supervisor: ____________________________________________________
May we contact him/her? ☐Y ☐N
Duties & Responsibilities:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Reason for Leaving:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Previous Employment:
Company: ___________________________________ Position Held: _________________________________
Street Address: _____________________________________________________________________________
City: ______________________________State: _____ ZIP: ____________ Ph: _________________________
Dates of Employment: From ________________ to ________________ Rate of Pay: _____________________
Name and Title of your immediate supervisor: ____________________________________________________
May we contact him/her? ☐Y ☐N
__________________________________________________________________________________________________
2353 Hassell Road, Suite 110, Hoffman Estates, IL 60169
ph: 847.884.7030 www.cepautism.org

3. Application for Employment
Duties & Responsibilities:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Reason for Leaving:
__________________________________________________________________________________________
__________________________________________________________________________________________
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EDUCATION & QUALIFICATIONS:
Please provide details about your education and qualifications.
Education:
Grad. Date
Name Location Major/Degree
Date Recv’d
High
School
College/
University
Post-
Graduate
Post-
Graduate
Qualifications:
Have you had any experience working with children with disabilities and/or autism? ☐Y ☐N
If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________________
2353 Hassell Road, Suite 110, Hoffman Estates, IL 60169
ph: 847.884.7030 www.cepautism.org

4. Application for Employment
Have you worked as a therapist doing ABA/RDI/Floortime/TEACCH, etc.? ☐Y ☐N
If yes, please describe your experience and duties.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list references for your therapy experience.
Length of
Phone
Name Employmen Reason for Leaving
Number
t
Have you accomplished any further education (workshops, classes, etc.), or are you contemplating any further
education? If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please provide at least 3 personal references:
How long has the
Phone Nature of
Name Address reference known
Number Relationship
you?
__________________________________________________________________________________________________
2353 Hassell Road, Suite 110, Hoffman Estates, IL 60169
ph: 847.884.7030 www.cepautism.org

5. Application for Employment
OTHER INFORMATION:
Please provide us with any other information that you may feel relevant. (Continue on a separate sheet if
necessary).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If you have a CV/Resume, please attach it to this application.
“I certify that the facts contained in this application are true and complete to the best of my knowledge and
understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize
investigation of all statements contained herein and the references listed above to give you any and all pertinent
information they may have, personal or otherwise.”
Signature: ______________________________________________________ Date: _________________
__________________________________________________________________________________________________
2353 Hassell Road, Suite 110, Hoffman Estates, IL 60169
ph: 847.884.7030 www.cepautism.org