EBLLC Job Application Form

Did you graduate from high school? *

Yes No

What high school did you attend?

Dates attended:________________________________________

What year did you graduate? *

Did you attend college or technical school? *

Yes No

What college or technical school of attendance? *

Dates attended:________________________________________

What year did you graduate? *

Experience with groups of children (Indicate ages of children, your duties, dates of time you worked in this position, reasons for leaving) *

Have you attended/completed any child care training courses? *

Yes No

If yes list below:

Upload Your Resume *

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Upload Your Cover Letter *

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Do you have a criminal record? *

Yes No

If yes, explain?

Have you ever been shown by credible evidence, e.g., a court order or jury, a department's investigation or other reliable evidence to have abused, neglected or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct? *

Yes No

If yes, explain?

Under the American with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applieds to the application process, any pre-employment testing, interviews and actual employment, but only if the program supervisor is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform the program director of your needs if it will impact your ability to perform the job for which you are applying.

Based on the aforementioned statement, do you require any accommodations? *

Yes No

Having read the job description for the position for which you are applying, are you in all respects able to adequately perform the duties as described?

Yes No N/A

If no, please explain?

Have you had Cardiopulmonary Resuscitation (CPR) training within the past two years?

Yes No

If yes, give expiration date?

Have you had first aid training within the past three years?

Yes No

If yes, give expiration date?

Bright From the Start: Georgia Department of Early Care Learning requires annual child care training, are you willing to participate? *

Yes No

Supplemental Documentation (Please upload any documentation that supports your employment application)

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I certify that all information on this application is correct. I have not given any false statement concerning my qualification requirements.

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Employment Application

EDUCATION

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