Employment Application

Employment Application
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
POSITION DESIRED FULL OR PART TIME
What type of shift would you like to work?
DESIRED WAGES
DATE AVAILABLE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(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.Format: (000) 000-0000.
BIRTHDATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Email
example@example.com
If you are under age 18. can you submit a work permit if hired?
I am over the age of 18
Are you a US citizen
If you are not a US citizen, do you have a VISA to work in the US?
If yes, what kind of VISA classification?
Visa Registration No
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has bond or security clearance ever been denied and/or canceled?
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?
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?
Do you have a criminal record?
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?
If yes, explain
Can you perform the essential function of the position for which you are applying?
If no, please explain
Do you have a valid drivers license
If yes, give the license number and class
Have you had CPR and first aid training within the past two years?
If yes, give expiration date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you attended any completed any child care training courses?
If yes, please list
Our state licensing department requires annual child care training, are you will to participate?
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Employment Application

Education