application. Personal Information Current Address: Home Phone: Cell Phone: E Mail: Position: Desired salary: If When? Consulting Orange Diagnosticss

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1 EMPLOYMENT APPLICATION Please complete all pages of this application. Personal Information Name (last name, first name): Social Security Number: Current Permanent Address (if different from above): Home Phone: Cell Phone: E Mail: Preferred method of contact? Are you 18 years of age or older? no, please state your age: Desired Employment Position: Which location/department are you applying to? Wolf Harbor School Program Consulting Orange School Program Advanced Intervention Diagnosticss Are you seeking full or part time employment? (circle one) Full Time Afterschool Programs Adult Program Day Care Part Time part time, how many hours a week are you available? Date you can start: Desired salary: Are you currently employed? so, may we contact your current employer? Have you ever applied to MBS/CCCD before? so, at which location and when? Have you ever worked for MBS/CCCD before? so: When? Name of last Supervisor? In what capacity? How did you hear about MBS/CCCD (e.g., friend, newspaper add, internet, etc.)? Reason for Leaving?

2 Education High school Name and Location of School # of years Attended Didd you Graduate? Year/Degree (please studied or major) e specify subjects Undergraduate Post Graduate Other Certification Information Certifications Held: (Please attach copies of certifications to this application) Special Education* BCBA D SLP Please list State: BCBA Other (please specify) BCaBA certified as a Special Education Teacher in the state of CT, please list your EIN # here: you ve taken courses in Special Education, but are not Certified, please provide the following information: Number of Credits completed in Special Education: Praxis I Information Date taken: Score: Praxis II Content Area: Date Taken: Score: Areas of Specialization Subjects of Special Study/Research: Specialized Training: Special Skills:

3 Current Primary Employment Current Employer: Description of job responsibilities: (use back of page if necessary) Additional Employment: (i.e., additional jobs held currently or previouss employment) ) Please circle current or previous Previous / Current Employer: Description of job responsibilities:

4 Additional Employment continued Current / Previous Employer: Description of job responsibilities: May we contact supervisor? References (Please list at least 2 professional and 1 personal connection who are not related to you and you have known for at least 1 year) Name Address Businesss Years Phone Known number Service Record Branch of service: Discharge Datee and Rank:

5 Criminal Background YOU ARE NOT REQUIRED TO DISCLOSE THE EXISTENCE OF ANY ARREST, CRIMINAL CHARGE OR CONVICTION, THE RECORDS OF WHICH HAVE BEEN ERASED PURSUANT TO SECTION 46B 146, 54 76O OR A OF THE GENERAL STATUTES. CRIMINAL RECORDS SUBJECT TO ERASURE PURSUANT TO SECTION 46B 146, 54 76O OR A ARE RECORDS PERTAINING TO A FINDING OF DELINQUENCY OR THAT A CHILD WAS A MEMBER OF A FAMILY WITH SERVICE NEEDS, AN ADJUDICATION AS A YOUTHFUL OFFENDER, A CRIMINAL CHARGE THAT HAS BEEN DISMISSEDD OR NOLLED, A CRIMINAL CHARGE FOR WHICHH THE PERSON HAS BEEN FOUND NOT GUILTY OR A CONVICTION FOR WHICH THE PERSON RECEIVED AN ABSOLUTE PARDON. IF YOUR CRIMINAL RECORD HAS BEEN ERASED PURSUANTT TO SECTION 46B 146, 54 76O OR A YOU ARE DEEMEDD TO HAVE NEVER BEEN ARRESTED WITHIN THE MEANING OF THE GENERAL STATUTES WITH RESPECT TO THE PROCEEDINGS SO ERASED AND MAY SO SWEAR UNDER OATH. Have you been convicted of a crime and/or misdemeanor within the past 5 years? yes, please explain (will not necessarily exclude you from consideration): Check appropriate statements below. Then sign and date the form. NOTE: Twoo statements must be marked. 1. At the time of submitting this application, I have been convicted of a crime.* 2. At the time of submitting this application, I have criminal chargess pending against me.* 3. At the time of submitting this application, I have not been convicted of a crime 4. At the time of submitting this application, I do not have criminal charges pendingg against me. Signature and Date I certify that the facts contained in this application are true and complete to the best of my knowledge and belief. I also understand and agree that no representative of Milestones Behavioral Services,, Inc. ( MBS ) has any authority to enter into agreement for employment for any specified period of time or to make any agreement contrary to the foregoing unless it is in writing and signed by an authorized MBS representative. Finally, I understand that employment, if offered, is contingent upon proof of citizenship or employability under the requirements of the Immigration Reform Control Act (IRCA). Signature: Date: