WPCC Application for Employment

WPCC Application for Employment

Please Print & Fully complete both pages
Date of Application

Month Day Year
Date
Full Name *

First Name Middle Name Last Name
Last four digits of SSN *
Current Home Address *

Street Address

County

City State

Zip Code
Phone Number (where you can best be reached) *

Area Code Phone Number
Email Address
example@example.com
Position you are applying for: *
Date of Birth *

Month Day Year
Date
N. C. Driver's License Number
Have you ever been convicted of breaking a law other than a minor traffic violation? If YES, give the date and explain fully below. *

YES NO
If YES above, please use this space to give the date and explain fully.
Have you ever had an abuse or neglect or child maltreatment substantiation? *

YES NO
If yes, list county/State and give the date and explain fully. Make sure to include the offense(s) and how recently you were convicted. This will be evaluated in relation to the job for which you are applying.

References & Work History
List the the names, phone numbers & emails of THREE people we may contact as references:
Work History #1

If you have not had work history please include internships or volunteer experience you have had related to early childhood.
Current or Last Employer
Address
Job Title
Supervisor's Name
Date Employed

Month Day Year
Date
Date Seperated

Month Day Year
Date
Reason for Leaving
May we contact your employer?

YES NO
Starting Salary
Please include per week, per hour, per month, etc. as applicable
Ending Salary
Please include per week, per hour, per month, etc. as applicable
Did you work full-time or part-time?

Full-Time Part-Time
If you worked part-time, how many hours per week did you work on average?
Please list duties you were responsible for
Work History #2

If you have not had work history please include internships or volunteer experience you have had related to early childhood.
Current or Last Employer
Address
Job Title
Supervisor's Name
Date Employed

Month Day Year
Date
Date Seperated

Month Day Year
Date
Reason for Leaving
May we contact your employer?

YES NO
Starting Salary
Please include per week, per hour, per month, etc. as applicable
Ending Salary
Please include per week, per hour, per month, etc. as applicable
Did you work full-time or part-time?

Full-Time Part-Time
If you worked part-time, how many hours per week did you work on average?
Please list duties you were responsible for
Please share any additional information that you believe may be pertinent or that you would like to share.
I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures are given to meet position qualifications.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

WPCC Application for Employment

Education

High School

Undergraduate Degree

Graduate Degree

Education, Vocational Schools, etc.

References & Work History

Work History #1

Work History #2