Employment Application Form

We consider applicates for all positions without regard to race, color, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
Position Applying for
How were you referred to us?*

Walk-InEmployeeFacebookOther (please specify)Relative
Name:*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number:*

Area CodePhone Number
E-mail Address:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you attend church?*

YesNo
If yes, please give name of church*
Do you know and understand the doctrine of the Holy Bible?*

YesNo
Will you be able to work within the belief structure?*

YesNo
Best time to contact you at home?*
Do you have children that would be using GBCLC's services?*

YesNo
If so, what are the ages of your children?
Have you ever filled out an application with us before?*

YesNo
Do you have friends or relatives that work here?*

YesNo
Are you currently employed?*

YesNo
May we contact your present employer?*

YesNo
The VA Dept. of Edu requires that each staff member provide a Physician's Statement which states "I certify that Employee Name is free from any disability which would prevent him/her from caring for children under his/her from caring for children under his/her supervision." Will you be able to provide this statement with a physician's signature?*

YesNo
Are you willing to take training classes offered through the school or the county that would help prepare you to work with children of all ages?*

YesNo
Are you prevented from lawfully becoming employed in the USA because of Visa or Immigration status? (Proof of citizenship or immigration status will be required upon employment).*

YesNo
Date available for work? *
Desired salary range?*
Are you available to work*

Full-timePart-timeMorningAfternoonEvening
Have you ever been convicted of a felony or a misdemeanor, or been involved with a child abuse or neglect court action official investigation?*

YesNo
Job Skills & Training
Describe your skills:*
Training or Certifications:*
Education
HighSchool Diploma?*

YesNo
Undergraduate College Course of Study?
Other?
Employment Experience
1. Employer*
Phone*
Address
Job Title*
Dates Employed (From/To)*
Salary*
Reason for leaving*
2. Employer*
Phone*
Address
Job Title*
Dates Employed (From/To)*
Salary*
Reason for leaving*
References

Please list two (2) references.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty: