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Employment
dalemcbroom
2021-04-13T20:42:53-04:00
Employment Opportunity
It’s not just a career. It’s a calling. Join our staff and pursue your calling.
Step
1
of
5
20%
Applicant Information
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Date Available
*
MM slash DD slash YYYY
Birthdate
*
MM slash DD slash YYYY
Position Applied for:
*
Are you a citizen of the United States?
*
Yes
No
If no, are you authorized to work in the U.S.?
*
Yes
No
Have you ever worked for this company?
*
Yes
No
If yes, when?
*
Have you ever been convicted of a felony?
*
Yes
No
If yes, explain:
*
Have you ever been reported for child abuse or neglect?
*
Yes
No
If so, what and when?
*
Emergency Contact Information
*
Name
Relationship
Phone Number
Education
High School
*
Address
Street Address
Address Line 2
City
State / Province / Region
Dates Attended
*
From: YY To: YY
Did you graduate
*
Yes
No
College
Address
Street Address
Address Line 2
City
State / Province / Region
Dates Attended
From: YY To: YY
Did you graduate
Yes
No
Degree
Other/Vocational
Address
Street Address
Address Line 2
City
State / Province / Region
Dates Attended
From: YY To: YY
Did you graduate
Yes
No
Degree
References
Please list three professional and character references.
Name
*
First
Last
Relationship
*
Company
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Name
*
First
Last
Relationship
*
Company
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Name
*
First
Last
Relationship
*
Company
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Previous Employment
Company 1
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
Job Title
Supervisor
Responsibilities
Dates worked
MM/YY-MM/YY
May we contact your previous supervisor for a reference?
Yes
No
Company 2
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
Job Title
Supervisor
Responsibilities
Dates worked
MM/YY-MM/YY
May we contact your previous supervisor for a reference?
Yes
No
Company 3
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
Job Title
Supervisor
Responsibilities
Dates worked
MM/YY-MM/YY
Reson for leaving
May we contact your previous supervisor for a reference?
Yes
No
Experience with Young Children
Place
Purpose
Dates
Contact Person
Disclaimer & Signature
TCA 14-10-129 states that “each person applying for work with children as a volunteer or as a paid employee...shall complete an application on a form prescribed or approved by the Department of Human Services...It shall be unlawful for any person to falsify any information required on the application. Knowing failing to disclose required information shall be deemed to be falsification to the same extent as providing false information.” By signing the 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 the expressed purpose of pre-employment screening.
Signature
Date
MM slash DD slash YYYY
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