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.Format: (000) 000-0000.
Social Security Number*
Date of Birth*
MM/DD/YYYY
Email *
example@example.com
Have you ever filed an application with us before?*

YesNo
If "Yes," give Date
Have you ever been employed with us before?*

YesNo
If "Yes," give Date
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

Rows	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.

Rows	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 Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*
Employment Reference #2 - Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*
Employment Reference #3 - Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 #*
Format: (000) 000-0000.
Job Title*
Supervisor*
Reason for Leaving*
Dates Employed (From - To)*
Work Performed*
Hourly Rate/Salary (Starting - Final)*
Employer #2
Address
Telephone #
Format: (000) 000-0000.
Job Title
Supervisor
Reason for Leaving
Dates Employed (From - To)
Work Performed
Hourly Rate/Salary (Starting - Final)
Employer #3
Address
Telephone #
Format: (000) 000-0000.
Job Title
Supervisor
Reason for Leaving
Dates Employed (From - To)
Work Performed
Hourly Rate/Salary (Starting - Final)
Employer #4
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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

PCFAXWordExcelProduction/Mobile MachineryOther
If Production/Mobile Machinery was selected, please list:
If "Other" was selected, please list:
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 the activities involved in such a job or occupation is attached.*

YesNo
Name*

First NameLast Name
Maiden Name (if applicable)
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Licensed/Registered Approved Facility/Provider
Address (Street, City, State, Zip Code)
Have you lived outside of Virginia in the past five years?*

YesNo
If yes, what state(s) have you lived in:
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 Virginia)Yes (Pending in Virginia)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 Virginia)Yes (pending outside Virginia)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 Virginia)No (in Virginia)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of Virginia?*

Yes (outside Virginia)No (outside Virginia)
If Yes, specify state, or other location
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*
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