Employment Application

Employment Application
DATE

MonthDayYear
Date
POSITION DESIRED FULL OR PART TIME
What type of shift would you like to work?

12 hour shifts (1-3 shifts a week)4-8 hour shifts (2-5 shifts a week)
DESIRED WAGES
DATE AVAILABLE*

MonthDayYear
Date
(First)*
(Middle)
(Last)*
SPOUSE'S NAME IF MARRIED
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
BIRTHDATE*

MonthDayYear
Date
Social Security
Email
example@example.com
If you are under age 18. can you submit a work permit if hired?

YESNO
I am over the age of 18

yes
Are you a US citizen*

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?
Visa Registration No
Expiration Date

MonthDayYear
Date
Has bond or security clearance ever been denied and/or canceled?

YesNo
If yes, please explain
Education
High School
Dates
Diploma or Certification
College
Dates
Degree
Other Education
Dates
Degree or certification
(attach any documentation go qualifying education)

Cancelof
EXPERIENCE WITH CHILDREN (Indicate ages of children, your duties, and dates you worked or volunteered.)
(Attach any documentation of experience working with children.)

Cancelof
Do you have any children that need child care while you are at work?

YesNo
If yes, please list their name and ages
(Please note: While we do offer child care benefits for our staff, enrollment is not guaranteed. It depends on our available space and the number of staff children currently enrolled)
LIST YOUR TEN-YEAR EMPLOYMENT HISTORY BEGIN 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. EXAMPLE: STUDENT, HOUSEWIFE, UNEMPLOYED, ETC.
From: To:
Name, Phone #, Address of employer
Position and Duties
Reason For Leaving
From: To:
Name, Phone #, Address of employer
Position and Duties
Reason For Leaving
From: To:
Name, Phone #, Address of employer
Position and Duties
Reason For Leaving
From: To:
Name, Phone #, Address of employer
Position and Duties
Reason For Leaving
May we contact previous employers?*

YesNo
Do you have a criminal record?*

YesNo
If yes, explain
Have you ever been shown by credible evidence, e.g., a court order or jury, a department investigation or other reliable evidenceto 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, explain
Can you perform the essential function of the position for which you are applying?*

YesNo
If no, please explain
Do you have a valid drivers license*

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

YesNo
If yes, give expiration date

MonthDayYear
Date
Have you attended any completed any child care training courses?*

YesNo
If yes, please list
Our state licensing department requires annual child care training, are you will to participate?*

YesNo
I hereby certify that all the information provided in this employment application is true and complete. I understand that false information or the omission of information may disqualify my candidacy and may be grounds for termination 1 further understand that I am applying to a Drug Free Workplace and may be required to submit to testing for the presence of drugs as a condition for employment.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Employment Application

Education