Employee Application Form
Thank you for your interest in joining The Cub House team. Please complete all sections of this application.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Desired Position
*
Infants
Toddler
Pre School
School Age
Other
Employment Type
*
Full Time
Part Time
Substitute
Please specify
Available Start Date
*
-
Month
-
Day
Year
Date
Do you have experience working with groups of children?
*
Yes
No
Age Groups
*
Infants (0–12 months)
Toddlers (1–2 years)
Preschool (3–4 years)
School Age (5+ years)
Are you able to perform the essential duties of the position you are applying for?
*
Yes
No
Do you have a clean background check with no disqualifying records?
*
Yes
No
Have you worked in child care since March of 2018?
*
Yes
No
Have you ever been convicted of a felony, or been involved with child abuse or neglect court action or official investigation? if yes please explain
*
Yes
No
Explanation
*
List of Three Personal References
*
Rows
Full Name
Phone Number
Relationship
Reference 1
Reference 2
Reference 3
Back
Next
Education
High School Graduate
*
Yes
No
College Experience
*
Yes
No
Major
*
Degree Achieved
*
If you are not educated in early childhood, you must be willing to attend classes. Are you willing to attend night and weekend classes to achieve any early childhood degree?
*
Yes
No
Employment History
Please list your most recent employment history, starting with the most recent position.
*
Back
Next
Louisiana Child Care Civil Background Check Initial Request Form
This form is intended for provider/entity use as a convenient way to obtain all pertinent information from the applicant. This information must be entered online through the Child Care Civil Background Check System at: https://cccbcldoe.la.gov All items marked with * are required for submission in the CCCBC System.
Social Security Number
*
Date of Birth
-
Month
-
Day
Year
Date
Full Name as it appears on government identification
*
Last Name
First Name
Middle Name
Suffix
Aliases, Nicknames, Tribal Names, including names from previous marriages
*
Applicants Personal Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address if different on Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Marital Status
*
Single
Married
Widowed
Separated
Divorced
Maiden Name
Sex
*
Please Select
Male
Female
Height
*
Weight
*
Photo Identification Type
*
Identification Number
*
Issued by (State)
*
Expiration Date
*
-
Month
-
Day
Year
Date
Hair Color
Eye Color
Race
Any Tattoos, scars, or distinguish marks, if so describe (including finger scarring)
Back
Next
Residential History for the past 5 years
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: