School for Amazing Kids™ Employment Inquiry Form

School for Amazing Kids™

Employment Inquiry Form
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Street Address
Apartment/Unit
ZIP Code
Have you lived outside of the State of Alabama in the last 5 years?
E-mail Address
example@example.com
Cell Phone Number
Date of Birth

MonthDayYear
Date
Date Available

MonthDayYear
Date
Position You Are Interested In
Social Security No.
Desired Hourly Rate
Position Interested In
Are you a citizen of the United States?
If no, are you authorized to work in the United States?
Have you ever worked for this company?
If so, when?
Have you ever been convicted of a felony?
If yes, explain
Education / Training
High School
Address
From
To
Did you graduate?
Degree
College
Address
From
To
Did you graduate?
Degree
Other
Address
From
To
Degree
References

Please list 3 non-family member references. NOTE: One must be a previous employer if you have been previously employed.
Full Name
Relationship
Phone
Format: (000) 000-0000.
Email
Full Name
Relationship
Phone
Format: (000) 000-0000.
Email
Full Name
Relationship
Phone
Format: (000) 000-0000.
Email
Previous Employment
Company Name
Phone
Format: (000) 000-0000.
Address
Supervisor
Job Title
Starting Rate of Pay
Ending Rate of Pay
What were your responsibilities?
Start Date
End Date
Reason for Leaving
May we contact your previous supervisor for a reference?
Company Name
Phone
Format: (000) 000-0000.
Address
Supervisor
Job Title
Starting Rate of Pay
End Rate of Pay
What were your responsibilities?
Start Date
Leave Date
Reason for Leaving
May we contact your previous supervisor for a reference?
Miltary Service
Type of Service
From
To
Type of Discharge
If other than honorable, explain
Work Availability
What days are you available to work?
Please note: We open at 6:00 AM and Close at 6:30 PM. Please indicate a “window” within which you can work. For example, people desiring as many hours as possible, should write “open” to “close” where ever possible. If you put “open” to “close” as your availability, it doesn’t mean that we will schedule you for the entire time; it only means you are available for work within that window. The greater your availability, the more likely you’ll be scheduled for the hours you desire.
What hours are you available to work?
Maximum # of hours per week you would like to work
How did you hear about us?

Other
Criminal History Background Information Checks:
In accordance with Alabama law, (Act 2000-775, effective November 1, 2000), the criminal history background information check shall be completed on each substitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact with the children or unsupervised access to the children shall be reviewed. You must complete a Mandatory Criminal History Notice Form and a Criminal History Information Consent and Release Form. There is a cost for the criminal history check (around $50) this fee will be paid through the Cogent System. If you previously had a criminal history check done for the Department of Human Resources, through the Cogent System in the last five (5) years and the required information is on file, it is not necessary to complete a criminal history check.
Are there any criminal charges against you?
If yes, give details.
Clearance of State Central Registry on Child Abuse/Neglect:
A completed REQUEST FOR CLEARANCE OF STATE CENTRAL REGISTRY O CHILD ABUSE/NEGLECT (DHR- DFC-1598 shall be obtained for each caregiver, substitute, volunteer, domestic worker, and any other person who has contact with the children or unsupervised access to the children.
Has abuse or neglect ever been substantiated by AL DHR Child Abuse/Neglect (CA/N) Central Registry Clearance?
Statement of Health:
I recognize that caring for children is an active, demanding and sometimes strenuous occupation. Providing excellent care for children requires constant and frequent lifting, bending, squatting, walking running and climbing. There are no physical or other limitations on my ability to meet these demanding physical requirements. Initial Below.
Disclaimer and Signature
By signing this form, I am affirming that the statements I have made in this inquiry form are true and factual to the best of my knowledge; and I am granting permission for all persons, organizations, or agencies listed above to be contacted for information regarding my background. If this inquiry leads to employment, I understand that false or misleading information in this inquiry or interview may result in immediate termination of my employment.
Sign Below
Date

MonthDayYear
Date
THANK YOU!!
Should be Empty:

School for Amazing Kids™

References

Work Availability

Criminal History Background Information Checks:

Clearance of State Central Registry on Child Abuse/Neglect:

Statement of Health:

Disclaimer and Signature