Perry Prep Application for Employment

Application for Employment

Perry Prep Learning Center
Date*

MonthDayYear
Date
Date Available*

MonthDayYear
Date
Position Desired*
Full Name*

First NameMiddle NameLast Name
Email*
example@example.com
Spouse's Name

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Date
Social Security Number*
If you are under age 18, can you submit a work permit if hired?

YesNo
If you are not a US citizen, do you have a VISA to work in the US?

YesNo
If yes, what kind of Visa classification do you have?
Visa Registration Number
Expiration Date
Has bond or security clearance ever been denied and/or canceled?

YesNo
If yes, please explain:

Education (Attach documentation of qualifying education)

	Dates	Diploma, Certificate, Degree
Elementary
Secondary
College
Other

Experience with groups of children:
(Indicate ages of children, your duties, dates of time you worked in this position, reasons for leaving). Attach documentation of experience working with children
Have you attended/completed any child care training courses?*

YesNo
If yes, list:
Do you have a criminal record?*

YesNo
If yes, explain:

PLEASE LIST EMPLOYMENT HISTORY FOR THE PAST TEN YEARS, BEGINNING WITH YOUR MOST CURRENT OR LAST EMPLOYER. If you have been unemployed during any time within the past ten years, list how you spent your time, e.g. student, housewife, unemployed, etc. If you need additional space, please use separate employment record form.

	Name & Address of Employer	Position	Dates From-To
Employer 1
Employer 2
Employer 3
Employer 4
Employer 5

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? *

YesNo
If yes, please explain:
Under the American with Disabilities Act of 1991, this program is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applies 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.
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?*

YesNo
If no, please explain:
Do you have a valid driver’s license?*

YesNo
If yes, give license number and class of license:
Have you had CPR training within the past two years?*

YesNo
If yes, give training date:
Have you had first aid training within the past three years?*

YesNo
If yes, give training date:
Bright from the Start: Georgia Department of Early Care Learning requires annual child care training, are you willing to participate?*

YesNo
Upload References & Certifications

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

Clear
Date*

MonthDayYear
Date
Should be Empty: