TUC Employment Application

Team Up Connections Employment Application
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Full Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number
SC or NC Driver's License Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Applied For:
Have you ever been convicted of breaking a law other than a minor traffic violation?
If Yes, please give the date and explain in full.
The offense(s) and how recently you were convicted will be evaluated in relation to the job for which you are applying.
Have you ever had a Department of Social Services (DSS) substation?
If Yes, please list the county/state, give the date, and explain in full.
Education
Please choose the highest level of education completed:

Please list the schools you have attended:

Rows	Name and City	Dates Attended	Course of Study	Degree/Diploma
High School


College or University


Graduate or Professional


Educational, Vocational Schools, etc.

Child care training you have completed in the last 3 years (such as first aid, CPR, CDA, ITS-SIDS, etc.):
Other Certifications (CDL, Instructor Certifications, etc):
Do you speak any languages other than English? If so, which language(s)?
Employment History
Current or Last Employer
List any child care experience first.
Job Title
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Number Supervised by You
Date Employed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Separated

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part-Time or Full-Time:
Years and Months Employed
If part time, how many hours per week?
Duties:
Current or Last Employer
Job Title
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Name
Number Supervised by You
Date Employed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Separated

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part-Time or Full-Time:
Years and Months Employed
If part time, how many hours per week?
Duties:
Professional References

Please list the names, phone numbers, and addresses of two people we may contact as references.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal References

Please list the names, phone numbers, and addresses of three people you would like to use as character references (only people you have known for at least one year). Include at least one relative. Any information Team Up Connections Mentoring Program gathers from these references will be held as confidential and not released to you, the applicant.
Relative's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Applicant:
Length of relationship?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Applicant:
Length of relationship?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Applicant:
Length of relationship?
Information Release
I, *, understand it will be necessary for Team Up Connections Mentoring Program to conduct a background check regarding my driving record, criminal history, personal references, and employment.

I authorize Team Up Connections to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in a mentoring program. Further, I provide permission for Team Up Connections to conduct the same investigation of my background in previous states in which I have resided.

Further, I understand that information about myself will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.
Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Driver's License Number
State of License
Please list any other cities, state, and dates of residency during the past 10 years:
Please list City, State, and Start of Residency Month/Year to End of Residency Month/Year.
Mentor Interest Survey

This information will be used for the purposes of matching you, as a potential mentor, with a potential mentee (if applicable to the role you have applied for).
Full Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please complete all of the following. This survey will help Team Up Connections Mentoring Program know more about you and your interests and help us find a good mentee match for you.
What are the most convenient times for you to meet with your mentee? Please check all that apply.

Other
Please indicate which age group(s) you are most interested in working with:
Is there a particular gender or ethnicity of youth that you feel would be a best fit for you as a potential mentor?
Do you speak any other languages other than English? If so, which language(s)?
Are you comfortable and willing to work with a child who has disabilities or special needs?
If Yes, please specify disabilities that you would be willing to work with and any special training you have received that may be relevant.
What are some of your favorite things that you like to do with other people?
What are your favorite subjects to read about and why?
What is your previous or current job and how did you choose this field?
What is one goal you have set for your future?
If you could learn something new, what would it be and why?
What person do you most admire and why?
Describe your ideal Saturday.
Please check all activities that you are interested in:
Please list any other areas of strong interest:
I, *, certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal on unemployment shall be mandatory if fradulent disclosures are given to meet position qualifications.
Signature of Applicant
Date of Signature

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

Team Up Connections Employment Application

Education

Employment History

Professional References

Personal References

Information Release

Mentor Interest Survey