Employment Application Form

Employment Application

Clay County Child Care Center and Head Start/Early Head Start in Clay, Cloud, Ottawa, Republic and Washington Counties. Equal Opportunity Employer
Name:

First Name Middle Name Last Name
Birth Date

Month Day Year
E-mail Address:

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
How were you referred to us? *

Walk-In Employee Newspaper Ad Facebook Other (please specify)
Others:
Upload Resume:
Type of Work Desired
Indicate the position for which you are applying. *
Bus Driver, Sub, Center Aid, Family Consultant, etc.
Do you wish to work: *
What is your minimum salary requirement?
Date available to begin work *

Month Day Year
Date
Do you have any commitments to another employer or project, which might affect your employment with us?
Job Skills & Training
Computer experience?
Please explain your experiences/skills in dealing with young children, or experiences with Head Start/Early Head Start: *
Are you legally authorized to work in the U.S.? *
Are you prevented from lawfully becoming employed in this country because of VISA or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.) *
Are you below the age of 18? *
Have you previously applied for employment here? Explain *
Driving Record
Do you have a valid Driver's Licence? *
License number: *
Do you have a valid KS Commercial Driver's Licence? *
Have you had a moving violation within the past year? *
Have you had an accident within the past 2 years? *
Has your license ever been revoked or suspended? *
Please explain any answers in this section, which might need further explanation:
Employment History

List present employer or most recent employer first. Use additional paper if you wish to include more than 3 employers.
*
Employed From:

Month Day Year
To:

Month Day Year
Date
Your Salary
Start $
Your Salary
End $
Job Duties *
What did you do at this job?
*
Employed From:

Month Day Year
To:

Month Day Year
Date
Your Salary
Start $
Your Salary
End $
Job Duties *
What did you do at this job?
*
Employed From:

Month Day Year
To:

Month Day Year
Date
Your Salary
Start $
Your Salary
End $
Job Duties *
What did you do at this job?
With this signature I give permission for the Clay County Child Care Center and it's Head Start/Early Head Start programs to contact my employers to request a reference and/or employment information. I hereby release previous employers froma ny liability for any information which they provide.
Signature *

Signature: Clear
Date *

Month Day Year
Date

Educational Data

Print Name, Number and Street, City, State and Zip Code for each School Listing

No. of Years Completed

Degree, Major or Type of Course

High School

College

Graduate School

Trade, Bus. Night, or Corres.

Other

References

Do not use employers or relatives in this space. Please list 3 or more individuals whom are willing for us to contact for personal references. INCLUDE PHONE NUMBERS. References will be checked carefully and will influence hiring decisions.

Type a question

Name and Address

Occupation

Years Known

Phone Number

Reference

Reference Authorization

I herein authorize my current and former employers and references to furnish any information about me and about my work expereince to the Clay County CHild Care Center (Head Start/Early Head Start). I release my current and former employers and references from any and all liabilites or damages of any nature as a result of providing such information.

I understand and consent to having criminal and arrest record checks as well as background checks by the Kansas Bureau of Investigation and KS Central Registry as a condition for consideration of my application.
Applicant Signature: *

Clear
Date *
Drug Testing

This agency is a drug-free workplace. Employees may be screened prior to employment or at any given time during their employment with this agency.
Should be Empty: