Head Start Job Application Form

Avoyelles Child Development Services, Inc. Application for Employment

PO BOX 153 Moreauville, LA 71355 | (318)985-2154
Personal Information
Full Name*

First NameLast Name
Application Date*

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Cell Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact
Person to Contact in case of Emergency:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to you
Internals
If you are related to anyone working in this agency or the ACDS, Inc. Board, provide the following:
Name

First NameLast Name
Relationship to you:
*** Failure to disclose that you are related to staff or board will be considered a cause for termination if revealed after being hired. We have a nepotism policy.
Referred by:

First NameLast Name
Position Applying For:
Available start date:

MonthDayYear
Date
Have you ever applied with this agency before?

YesNo
If yes, when?
If yes, what position?

Legal
Are you legally eligible to work in the United States?*

YesNo
Have you ever worked for this company before?*

YesNo
If yes, when?
Type in time-frame employed.
Have you ever been convicted of a felony? A plea of guilty or nolo contenders of a felony, or any offense of a violent or sexual nature, or any offense involving a juvenile victim?*

YesNo
If yes, please state the matter pf the conviction:
Please be advised that any offer of employment is contingent upon criminal record clearance. If a felony conviction is revealed after employment, employment will be terminated immediately.

Employment History

1 of 4 (From most current, to oldest employers. Please list employers for the span of the last 10 years)
What is your current employment status?*

EmployedUnemployedSelf-EmployedStudent
Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
From

MonthDayYear
Date
To

MonthDayYear
Date
Currently Employed with them?

YesNo
Supervisor's Name
List your responsibilities
May we contact?

YesNo

References

1 of 3
Name of Reference 1

First NameLast Name
Phone Number of Reference 1
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 1 Company
Years Acquainted with Reference 1

References

2 of 3
Name of Reference 2

First NameLast Name
Phone Number of Reference 2
Please enter a valid phone number.Format: (000) 000-0000.
Address of Reference 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 2 Company
Years Acquainted with Reference 2

References

3 of 3
Name of Reference 3

First NameLast Name
Phone Number of Reference 3
Please enter a valid phone number.Format: (000) 000-0000.
Address of Reference 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference 3 Company
Years Acquainted with Reference 3

Avoyelles Child Development Services, Inc. Application for Employment