Employment Application

Application Form for Staff

Including caregivers, employees, teachers, substitutes, volunteers, cooks, bus drivers, domestic workers
Date*

MonthDayYear
Date
Position*
Name*

First NameMiddle NameLast Name
Maiden Name (if applicable)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Drivers License Number*
Expiration Date of Drivers license*

MonthDayYear
Date

Education

	School/Institution	Dates Attended	Diploma/Degree/Certificate
Elementary
High School
College
Graduate
Other

CHILD CARE TRAINING:

List all courses, workshops, and conferences related to child development and early childhood education. Attach additional pages if necessary. Attach copies of certificates received. Sponsor Workshop/conferencehours

	Title of course/ Workshop/ conference	Sponsor	Location	Date (s)	Number of hours
1
2
3
4

EMPLOYMENT HISTORY:

List in order beginning with your most recent employment. Attach additional pages if necessary

	Employer	Employer's Address	Position/ Job	Date (s) Worked	Reason For Leaving
1
2
3
4

REFERENCES:

List at least three persons who are not related to you by blood, marriage, or adoption. to be contacted as references. At least one must be a former employer. Addresses must be complete and accurate.
Name of Former Employer*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
Criminal History Background Information Checks:

In accordance with Alabama law, (Act 2000-775, effective November 1, 2000), the criminal history background information check shall be completed on each substitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact with the children or unsupervised access to the children shall be reviewed.
Current Criminal Charges:
Are there any current criminal charges against you ?(Yes/No)*
If yes give details
Clearance of State Central Registry on Child Abuse/Neglect:
A completed REQUEST FOR CLEARANCE OF STATE CENTRAL REGISTRY ON CHILD ABUSE/NEGLECT (DHR-DFC-1598) shall be obtained for each caregiver, substitute, volunteer, domestic worker, and any other person who has contact with the children or unsupervised access to the children.

By signing this form, I am affirming that the above statements I have made are true and factual to the best of my knowledge; and I am granting permission for all persons, organizations, or agencies listed above to be contacted for information regarding my background.
Signature

Clear
Date

MonthDayYear
Date
Montclair Early Learning Center recognizes our employees as one of our greatest assets. We are committed to providing equal employment opportunities for all, without regard to race, color, religion, national origin, age, gender, marital status, sexual orientation and/or disability. These opportunities include, but are not limited to, recruitment, hiring, training, promotion, compensation, benefits and all other terms and conditions of employment.
Should be Empty:

Application Form for Staff

CHILD CARE TRAINING:

EMPLOYMENT HISTORY:

REFERENCES:

Current Criminal Charges: