Employee RBT Certificate

EMPLOYEE RBT CERTIFICATE

Employer Name:    Employee Name:

Personal Information

Position Information

Start date:    Salary (annual):

RBT Credential Details

RBT Certificate Number:    Issuing Board/Organization:

Date of initial certification:    Expiration/renewal date:

Competency assessment completed on:    Supervisor (BCBA) name:

Criminal background check performed: Yes    Background clearance status: Cleared Pending Not Cleared

Training and Supervision

Employment History (Most Recent)

Job title:    Dates employed:

Employment History (Previous)

Job title:    Dates employed:

Education

Graduation date:

References (Professional)

Legal Disclosures

At-Will Employment: Employment with this organization is at-will unless otherwise set forth in a separate written agreement signed by an authorized representative. Nothing in this certification alters the at-will nature of employment or creates any express or implied employment contract.

Equal Opportunity: The employer provides equal employment opportunity to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected by law. This certification will be administered consistent with that policy.

Applicant Certification & Authorization

I certify that the information provided in this Employee RBT Certificate is true, complete, and accurate to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may result in disciplinary action up to and including termination.

Authorization: I authorize the employer and its agents to contact prior employers, educational institutions, credentialing bodies, supervisors, and references to verify the information provided. I further authorize the employer to obtain criminal history and background checks necessary to satisfy job-related and legal requirements for employment and RBT practice.

Consent to Disclosure: I consent to provide copies of my RBT credential, competency assessment documentation, and any supervisory agreements to the employer for verification and maintenance of employment records.

Applicant acknowledges continuing education and renewal obligations associated with the RBT credential and agrees to notify the employer immediately of any suspension, revocation, lapse, or restriction on the credential.

I certify that all information provided is true and complete and authorize verification as stated above.

Employer Verification (to be completed by authorized representative)

Documents reviewed (check all that apply):
RBT certificate Competency assessment Supervisory agreement Background check

By signing below, the authorized representative confirms that the documents indicated above were reviewed and that the employee meets the employer's documented requirements to perform RBT duties consistent with applicable professional standards and agency policy.

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