JOB APPLICATION

Job Application

Full Name

Last 4 Digits of SSN

Address

Cell Phone

Birthday

Position Applied For

N. C. Driver’s License Number

Have you ever been convicted of breaking a law other than a minor traffic violation? If so, plase explan below.

Yes

If yes, please explain fully and include the date.

Have you ever had an abuse or neglect or child maltreatment substantiation?

Yes

If yes, list county/State and give the date and explain fully. (The offense(s) and how recently you were convicted will be evaluated in relation to the job for which you are applying.)

What is your highest level of education?

Please list schools attended (high school, colleges, universities, vocational schools, etc), dates attended, prgoram of study and if you graduated.

Child care training completed in the last three years (such as First Aid, CPR, Health and Safety Training, ITS-SIDS, CDA etc.):

List the names, addresses, and phone numbers of people we may contact as references:

References

Please list any childcare and education experience first.

Most recent employer. Please include employer's name, contact information, salary, hours worked, duties and if you were part time or full time.

I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures are given to meet position qualifications.

Your Signature

Thank you for applying.