Application for Employment APPLICATION FOR EMPLOYMENT Please answer each question fully and accurately. No action can be taken on this application until all questions have been answered. Name First Last Date of birth Date Format: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home phoneCell phoneSocial Security #Have you ever been employed here?YesNoIf yes, when?Number of days’ work missed in the past six months?Have you ever been convicted of any crime against a child?YesNoIf yes, please explainHas a court ever denied parental, custodial or visitation rights as a result of your neglect or abuse of a child?YesNoIf yes, please explainEDUCATION: Give name, address & location of school/college, highest grade completed, date of leaving:HIGH SCHOOL/GEDCOLLEGE/UNIVERSITYCollege MajorDegreeAdvanced degree or course workAdditional educational, vocational, technical trainingHEALTH: Do you have any physical limitations which would give you problems performing your job?YesNoIf yes, please explainPOSITION APPLIED FORWhy do you want to work in our program?What do you feel qualifies you for this job?REFERENCES: Give names, addresses and phone numbers of two people we may contact about you.NameTelephoneAddressNameTelephoneAddressWORK HISTORY: Please attach your resume or list below all present and past employment, beginning with the most recent, covering all periods of time. If self-employed, supply business references, Please give month and year.WORK HISTORY:Employer’s NameAddress & Phone #FromToDutiesSupervisorReason for leaving AFFADAVIT: I certify that everything in this application is true and correct to the best of my knowledge. I understand that misleading or incorrect statements or consequential omissions may render this application void or, if employed, would be cause for termination of employment. I authorize individuals or institutions named above to give any information regarding my employment, character and qualifications, hereby releasing them from all liability for issuing such information.YesNoSignatureDate Date Format: MM slash DD slash YYYY Date of employment Date Format: MM slash DD slash YYYY Date of termination Date Format: MM slash DD slash YYYY
