The Children

The Children's House
Application for Employment

Date: ____________

Social Security Number _____- _____- _____

NAME_________________________________ Age_____
ADDRESS __________________________
CITY __________________ STATE_______ ZIP CODE__________
TELEPHONE _______________
Date Available to start ________ Hours Available ___ Salary expected ________
Other names you have worked under ______________________________
Last physical examination date________ Last TB test date__________
Do you have any physical condition that may restrict your
performance of the job you are applying for? _____
List them if any ________________________________________________

High School:
Name ________________________ City/State __________ Year Graduated _____

College/University: (if more than 1, please list on separate sheet)
Name ________________________ City/State __________
Major ____________ Cert or Degree ____________ Completion Date _____

Licenses or certificates held, or credentials qualifying you for this employment:
____________________________________________________________
____________________________________________________________

Published materials or Awards: ___________________________________

EARLY CHILDHOOD COURSES TAKEN (if more than 3, please list on separate sheet)
________________________________________ Number of Units/Credits _____
________________________________________ Number of Units/Credits _____
________________________________________ Number of Units/Credits _____

Special skills or talents, which you may care to list:
____________________________________________________________
____________________________________________________________

Foreign Languages): ___________________________________________
Typing: ( )wpm Swimming instruction:___ Gymnastics____ Other:__________
Musical Instruments: _____________________ Art: ____ Other:__________

EMPLOYMENT HISTORY: (list most recent first)
Employer Name ____________________Address _________________________
Job Title _____________________________________________
Job Description _________________________________________________
Employed From ____________to ____________ Salary ______________
Are you currently employed by this employer? ______
May we contact this employer? ______
Reason for leaving _________________________________________

Employer Name ____________________Address _________________________
Job Title _____________________________________________
Job Description _________________________________________________
Employed From ____________to ____________ Salary ______________
May we contact this employer? ______
Reason for leaving _________________________________________

Employer Name ____________________Address _________________________
Job Title _____________________________________________
Job Description _________________________________________________
Employed From ____________to ____________ Salary ______________
May we contact this employer? ______
Reason for leaving _________________________________________

Volunteer or unpaid experiences: __________________________________

Professional References:
Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Personal References:
Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Name ___________________________ City/State _________________
Occupation _______________________ Phone __________________

Have you ever been convicted of a crime*? YES _____ NO ____
Date of conviction _______ City/State ____________ Case/Docket Number __________
Final Disposition _____________________________
(*Exclusions: Minor traffic violations for which the fine was not over $50.00,
or an offense which was settled in a juvenile court).

Why would you like to have this position?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
What do you feel most qualifies you for this position?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Would you be willing to continue your education by enrolling in certain courses or training programs that may be recommended? Yes _____ No _____

I hereby certify that all entries on this application for employment and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment in the service of The Children's House. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize The Children's House to rely upon and use, as it sees fit, any information received from such contacts.