7gg=====KKKKK U _____ The Children's House Application for Employment Date: ____________ Social Security Number _____- _____- _____Position applying for ________________ Full Time _____ Part-time _____ 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:__________ Membership in Professional Organizations: ___________________________ 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. Applicant Full Printed Name _____________________________ Applicant Signature ______________________ Date _________ hNz@z{d WORD{bin4224009725232rs   g PkFrs h ;-g00%J@@@@@@@@ Normal (Web)  ddggg g=/B