Employment Application

We are an equal opportunity employer and do not unlawfully discriminate in employment.  No question on this application is used for the purpose or limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law.  Equal access to employment, services and programs are available to all persons.  Those applicants requiring reasonable accommodations to their application and/or interview process should notify a representative of the organization.

Contact Information

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
e-mail Address:
Home Phone:
Cell Phone:


Employment Information

Position(s) applied for:
Type of employment desired: 
Full Time       Part Time        Temporary
Date you will be available to start work:
Desired Wage:

Are you able to meet the attendance requirements? No
Do you have any objection to working overtime if necessary?   Yes No
Have you ever been previously employed by our company?   Yes No
Can you submit proof of legal employment authorization and identity?   Yes No
If you are under 18 can you furnish a work permit if it is required? Yes No
Have you ever been convicted of a crime?  Yes No

If yes, please explain (a conviction will not automatically bar employment):

How were you referred to us?


Employment History
Please provide all employment information for your past four employers starting with the most recent.

Employer 1

Employer:
Position held:
Address:
Employer Phone:
Immediate supervisor and title:
Dates employed: 
Salary:
Job Summary:
Reason for leaving:

Employer 2

Employer:
Position held:
Address:
Employer Phone:
Immediate supervisor and title:
Dates employed: 
Salary:
Job Summary:
Reason for leaving:

Employer 3

Employer:
Position held:
Address:
Employer Phone:
Immediate supervisor and title:
Dates employed: 
Salary:
Job Summary:
Reason for leaving:

Employer 4

Employer:
Position held:
Address:
Employer Phone:
Immediate supervisor and title:
Dates employed: 
Salary:
Job Summary:
Reason for leaving:


Educational History

Did you complete High School? Yes        no
If yes, please list name and location.
College Degree Obtained?
  Associates Degree  
  Bachelors Degree
  Masters Degree
Area(s) of Concentration:
please list name and location.
Have you completed ECE 1? Yes        no
Have you completed ECE 2? Yes        no


Certification History

Have you completed First Aid? Yes        no Expiration date:
Have you completed CPR? Yes        no Expiration date:
Have you completed ServSafe? Expiration date:
Have you completed Administration of Medication? Yes        no  

 

References
Do not include relatives or employers.

1. Name: phone: years known:
2. Name: phone: years known:
3. Name: phone: years known:

Any additional questions and/or comments you would like to add?


I hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational intuitions, and references.  I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other person or organizations for providing such information. 

I understand that any misrepresentation or material omission made by me on the application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, wherever it may be discovered.

If I am employed, I acknowledge that there is not specified length of employment that this application does not constitute an agreement or contract for employment.  Accordingly, either I or the employer and terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof identify and legal work authorization within three days of being hired.  Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I see employment under these conditions:

I have met all eligibility requirements and wish to be considered for the following position(s) I have listed above.



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