Perry Prep Application for Employment

Date*

Date

Date Available*

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.Format: (000) 000-0000.

Birth Date*

Date

Social Security Number*

If you are under age 18, can you submit a work permit if hired?

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

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?

If yes, please explain:

Education (Attach documentation of qualifying education)

Rows	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?*

If yes, list:

Do you have a criminal record?*

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.

Rows	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? *

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?*

If no, please explain:

Do you have a valid driver’s license?*

If yes, give license number and class of license:

Have you had CPR training within the past two years?*

If yes, give training date:

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

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?*

Upload References & Certifications

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

Signature*

Date*

Date