Employment Application Form

APPLICATION FOR EMPLOYMENT
Position Applied For: *
Last 4 digits of Social Security Number (NOTE: Completion of Social Security number is optional. Failure to submit SSN on this form will not prohibit employment considerations. Social Security number may be required on other forms prior to employment.) *
Full Legal Name: *

First Name Middle Name Last Name
Complete Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell/Home Phone Number: *

Area Code Phone Number
E-mail Address:

Education:
Select highest grade completed *
If you did not complete high school, do you have a H.S equivalency diploma?

Yes No
Select the highest grade completed post high school education
Name/Location of Institution
Please submit most recent current college transcripts

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Experience:

Use Supplementary Experience Forms for additional space. Starting with the most recent,
describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skill
and abilities which demonstrate your qualifications for this position. You may list significantly
different jobs within the same organization as separate items.
Job #1
May we contact this employer?
Equipment Used:
Reason for Leaving:
Your name if different from the present:
Job #2
May we contact this employer?
Equipment Used:
Reason for Leaving:
Your name if different from the present:
Job #3
May we contact this employer?
Equipment Used:
Reason for Leaving:
Your name if different from the present:
Job #4
May we contact this employer?
Equipment Used:
Reason for Leaving:
Your name if different from the present:
Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, special achievements, or special skills: *

License (Include drivers), certificate or other authorization to practice a trade profession

	Type	License No.	Expiration Date	Granted By
1
2
3
4
5
6
7
8

References: These individuals will be contacted upon offer of employment

List names, addresses and relationship of three persons not related to you who know your
qualifications:
Reference 1
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Cell/Home Number *

Area Code Phone Number
Relationship
Reference 2
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell/Home Number *

Area Code Phone Number
Relationship
Reference 3
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell/Home Number *

Area Code Phone Number
Relationship
Upload Resume:

Miscellaneous:
A. List the subjects you have studied relative to the position for which you areapplying:
B. What experience have you had working with groups of children or youth?
C. Select which job status you would accept:

Full-time Part-time
D. For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?

Full-time Part-time
Under the Immigration Act of 1968, you will be required to fill out a certification
verifying that you are eligible to be employed and verify your identity. Further, you
will be required to provide documentation to that effect should you be employed.
E. Have you ever been arrested or convicted of a crime, misdemeanor, or felony? If yes, please state the date of the arrest, offense, outcome, and sentence:
CERTIFICATION:
I hereby certify that all entries on each sheet and all attachments are true and complete, and I
agree and understand that any falsification of information herein, regardless of the time of
discovery, may cause forfeiture on my part of any employment with Peake Childhood Center. I
understand that all information on this application is subject to verification, and I consent to
references of former employers a
Applicant's Signature:

Clear
Date:
Peake Childhood Center is an equal opportunity employer. In accordance with Federal law and
U.S. Department of Agriculture policy, this organization prohibits discrimination on the basis of
race, color, national origin, sex, age, religion,
political beliefs, disability, sexual orientation or marital or family status.
Should be Empty: