Child Development Center Employment Application

Child Development Center Employment Application
8491 CHAMBERLAYNE ROAD, RICHMOND, VA 23227 | (804) 262-7104
We consider applicants for all positions without regard to race, color, gender, national origin, age, disability, marital or veteran status. However, applicant must be a Christian and a tithing member of a local church.
Position(s) Applied For
Date of Application
MM/DD/YYYY
How Did You Learn About Us?

AdvertisementFriendWalk-InEmployment AgencyRelativeOther
Name (Last, First, Middle)
Address (Number, Street, City, State, Zip)
Day Time Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Date of Birth
MM/DD/YYYY
Have you ever filed an application with us before? If “Yes,” give Date

YesNo
Have you ever been employed with us before?

YesNo
May we contact your present employer and request a reference?

YesNo
If hired are you able to submit proof that you are eligible for employment in the United States? Proof of citizenship or immigration status will be required upon employment.

YesNo
On what date would you be available for work?
MM/DD/YYYY
You are available to work

Full TimePart TimeShift WorkTemporary
Are you currently on “lay-off” status and subject to recall?

YesNo
Can you travel if a job requires it?

YesNo
Education

	Name and Address of School	Course of Study	Years Completed	Diploma Degree
Elementary School
High School
Undergraduate College
Graduate Professional
Other (specify)

Indicate any foreign languages you can speak, read and/or write.

	FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

Describe any specialized training, Professional Licenses, Certifications, skills, job–related training in the US Military and extracurricular activities.
Employment References
Employment Reference #1 - Name
( ) Phone
Address
Employment Reference #2 - Name
( ) Phone
Address
Employment Reference #3 - Name
( ) Phone
Address
Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, gender, national origin, disabilities, or any other protected status.
Employer #1
Address
Telephone #
Job Title
Supervisor
Reason for Leaving
Dates Employed (From - To)
Work Performed
Hourly Rate/Salary (Starting - Final)
Employer #2
Address
Telephone #
Job Title
Supervisor
Reason for Leaving
Dates Employed (From - To)
Work Performed
Hourly Rate/Salary (Starting - Final)
Employer #3
Address
Telephone #
Job Title
Supervisor
Reason for Leaving
Dates Employed (From - To)
Work Performed
Hourly Rate/Salary (Starting - Final)
If you need additional space, please continue on a separate sheet of paper.
List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, national origin, age, ancestry, disability, or other protected status:
Additional Information
Other Qualifications: Summarize special job-related skills and qualifications acquired from employment or other experience.
Specialized Skills
Check Skills/Equipment Operated

PCWordProduction/Mobile Machinery (list):Other (list):FAXExcelOther
State any additional information you feel may be helpful to us in considering your application.
Please list any medical conditions/concerns that we should know about.
Are you able to obtain a certificate from a physician stating that you are free from any disability that would prevent you from caring for children

YesNo
If “No”, explain
Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing, in a reasonable manner, or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A description of theactivities involved in such a job or occupation is attached.

YesNo
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth of Virginia?*

Yes (convicted in VA)Yes (pending in VA)No
If Yes to convicted or pending, specify crime(s) and date(s)
2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth of Virginia?*

Yes (convicted outside VA)Yes (pending outside VA)No
If Yes to convicted or pending, specify crime(s), and state, or other location
3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of Virginia?*

Yes (in VA)No (in VA)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of Virginia?*

Yes (outside VA)No (outside VA)
If Yes, specify state, or other location
5. Do you use illegal drugs or engage in any type of drug abuse?*

YesNo
Please disclose any negative information regarding your character, reputation, moral history or criminal history that the church should be aware of:
By signing below, I authorize FLM to obtain information, written, oral or other, from any law enforcement agency, or other persons with knowledge of such information, bearing on my character, mode of living, criminal background. FLM reserves the right to conduct this inquiry at any time.
I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification and that making a materially false statement or affirmation is a Class I misdemeanor.
Signature

Clear
Date
MM/DD/YYYY
File Upload. Please upload both, the Pastoral Reference and the Physician's statement.

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Child Development Center Employment Application

8491 CHAMBERLAYNE ROAD, RICHMOND, VA 23227 | (804) 262-7104

Education

Employment References

Employment Experience

Additional Information

Specialized Skills