Employment Application

I Am Seeking

Date Available

Regular Employment    Summer Employment    Temporary Employment

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2007

Last Name

First Name

Middle Name

Home Street Address

City

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Telephone No.

-

Best Time to Contact

A.M.    P.M.

School Phone No. (if applicable)

-

School Address (if applicable)

City

State

Zip Code

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Emergency Contact (Name)

Street Address

State

Zip Code

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Relationship

Emergency Telephone No.

-

I am at least 21 years old

Yes    No

Per requilation, applicants must be at least 21 old to be epmloyed in child-care at Children's Center.

Are You a U.S. citizen?

Yes    No

If hired, you must present evidence of U.S. citizenship or your legal right to live and work in this country.

Social Security No.

- -

Position Desired

How did your learn of opening?

Referred by

Have you ever been employed by this agency?

Yes    No

Month         Year

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec    yyyy 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Position

Have you ever been convicted of a felony crime?

Yes    No

If hired, you will be required to submit for Child Abuse Clearence as well as a Criminal History Record Check. Certain felony crimes preclude individuals from being hired into a position with our agency.

If yes, describe in full

High School

City

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Diploma

Yes   No   G.E.D.

College

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Degree/Major

Did you Graduate?

Yes    No

Yes    No

Yes    No

Other (Vocational)

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Degree/Major

Did you Graduate?

Yes    No

Branch of Service

Highest Rank Attained

Length of Service

From 1 2 3 4 5 6 7 8 9 10 11 12 13 14 >15  To 1 2 3 4 5 6 7 8 9 10 11 12 13 14 >15

Speciality/Training

Employer 1

From

To

Title

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Address

City

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Immediate Supervisor

Telephone No.

-

Beg. Salary  End. Salary

Reason for Leaving

Employer 2

From

To

Title

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Address

City

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Immediete Supervisor

Telephone No.

-

Beg. Salary End. Salary

Reason for Leaving

Employer 3

From

To

Title

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

-m- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   -y- 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Address

City

State

--- Select One --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Immediate Supervisor

Telephone No.

-

Beg. Salary End. Salary

Reason for Leaving

Employer 4

From

To

Title