JOB APPLICANT INFORMATION

A person who has been convicted of a crime enumerated in subsection (a) who applies for employment with, is employed by, or seeks to provide caregiver services or is a caregiver at a facility is guilty of a misdemeanor and, upon conviction, must be fined not more than five thousand dollars or imprisoned not more than one year or both.

Last Name

First

Date

Street Address

Apartment/Unit #

City

Zip

State

Phone Number

Area Code Phone Number

E mail Address

example@example.com

Date Available

Date

Social Security No.

Desired Salary

Position Applied for

Are you a Head Start Parent?

Yes No

Are you a citizen of the United States?

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Have you ever worked for the company?

Yes No

Have you ever been convicted of a felony?

No

High School

Address

From

To

Degree

Did you graduate?

Yes No

College

Address

From

To

Did you graduate?

Yes No

Degree

Other

Address

From

To

Did you graduate?

Yes No

Degree

Full Name

Relationship

Company

Phone Number

Area Code Phone Number

Address

Full Name

Relationship

Company

Phone Number

Area Code Phone Number

Address

Full Name

Relationship

Company

Phone Number

Area Code Phone Number

Address

Company

Phone Number

Area Code Phone Number

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

Phone Number

Area Code Phone Number

Company

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

Company

Phone Number

Area Code Phone Number

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May we contact your previous supervisor for a reference?

YES NO

Branch

Rank at Discharge

Type of Discharge

If other than honorable, explain

From

To

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Nothing on this application is intended to create or imply a contractual relationship; if hired, the employee understands that employment is at-will and can be terminated with or without reason at any time. All new hires are subject to approval by the Executive Director and if the position is for the Head Start Program, approval from the Early and Preschool Policy Council is required. This application shall remain on file for a period of 6 months. If you wish to renew your application after this period of time, you may do so by calling this office.

Notice of Equal Opportunity – Beaufort-Jasper EOC will not discriminate against otherwise qualified persons on the basis of race, color, religion, national origin, sex, age, physical or mental handicap or disability in its recruitment, admissions, employment, facility and program accessibility or services. Under the Americans with Disabilities Act of 1991, this program is required to reasonable accommodate individuals with a disability. The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews, and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.

Signature

By typing your name in the box above, you certify that the information is correct and you are electronically signing this document.

Date

APPLICANT INFORMATION

EDUCATION

REFERENCES

PREVIOUS EMPLOYMENT

MILITARY SERVICE

DISCLAIMER AND SIGNATURE