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Application for Employment

 

Position for which you are applying:  

 Full–time

Part–time

 

Personal Information:

Name:

Last

First

Middle

Other Name(s) Used:á

Present Address:

     

Number and Street

City

State

Zip

Telephone (day)

Social Security #

 

Telephone (Evening)

Date of Birth

 

E–Mail Address

Driver License #

 

 

Education: (List in reverse chronological order)

Name of Institution

Location City/State

Diploma Degree Received

 

Other Professional Credentials, Certificates and Licenses:

Type Presently Held

ID Number

Expiration Date

     

 

 

Employment History: 

List your occupational and teaching experience for the last 7 years, listing most recent employment first.  Provide your complete employment history even if you attach a resume.  If you had more than one position with the same employer, list each position separately.  If more space is needed, continue on a blank sheet of paper using the same format.  Please explain gaps in employment.

 

Position

Employer

Supervisor

Title

Address

Number and Street

City

State

ZIP

Telephone

   

Full–Time

Part–Time

Start Date

End Date

  

Starting Salary

Ending Salary

Reason for leaving

Position

 

Employer

     

Supervisor

Title

     

Address

     

  

Number and Street

City

State

ZIP

Telephone

 

 Full–Time

 Part–Time

Start Date

End Date

Starting Salary

Ending Salary

 

Reason for leaving

     

During the selection process, we may conduct reference checks with employers and supervisors listed above as well as others.  If you do not want a certain employer or supervisor contacted initially, indicate who and why.

 

 

Professional References: 

List persons who can critically assess your work qualifications and job performance. 

Name

Name

Position

Position

Company/Organization

Company/Organization

Street Address

Street Address

City / State / Zip

City / State / Zip

Telephone

 

Telephone

 

Name

Name

Position

Position

Company/Organization

Company/Organization

Street Address

Street Address

 

City / State / Zip

City / State / Zip

 

Telephone

 

Telephone

 

 

Foreign Languages

Speak

Write

Read

Fluency

 Excellent     Good     Fair

Speak

Write

Read

Fluency

 Excellent     Good     Fair

Speak

Write

Read

Fluency

 Excellent     Good     Fair

 

List professional trade, business, or civic activities and offices held.

You may exclude those, which indicate race, color, religion, national origin, veteran status, ancestry, sex, sexual orientation, age, or disability.

 

Organization

Activities

Organization

Activities

     

 

 

Provide any additional data that will assist in the evaluation of your application.

 

 

General Information:

Yes

No

·         Are you able, upon employment, to submit verification that you are a United States citizen or are eligible to work in the United States:

The Immigration Reform and Control Act of 1986 requires us to obtain original documentation from every employee, which verifies identity and authorizes employment in the United States.

·         Have you ever been convicted, pled guilty to or pled no contest o any criminal offense by any court?  (Having a criminal record does not necessarily disqualify you for employment.  Each case is given individual consideration, based on job–related criteria. 

Attach additional pages to record the necessary information.

If yes, please note the date and place of each offense, the specific charge, the date and place of conviction, or plea, the fine or sentence received or the diversion program entered. 

·         Have you ever been dismissed from employment or resigned in lieu of being dismissed for inefficiency, delinquency, or misconduct?  If “yes” explain below.*

A yes answer will not automatically preclude you from employment consideration.

 

*Remarks/Explanations:

 

 

 Certification and Agreement of Applicant:

Please read carefully before submitting the application.

This application and all supporting documents become the property of Clermont Kidz and will not be returned.

Certification:  I hereby certify that all statements made on this application and any attachments are true and complete to the best of my knowledge.  I understand that any false, incomplete or incorrect statement may result in my dismissal from employment with Clermont Kidz to which I have applied.

I authorize Clermont Kidz to investigate my references, credit, work record, education, performance evaluations, criminal history or any other matters relating to my suitability for employment.  I authorize and direct my former or current employers and educational institutions to release to Clermont Kidz any information they may have concerning my employment or education.  I also authorize Clermont Kidz to obtain and review any documents or records, including credit, criminal history, drug screening and driving records, which are applicable to my employment.  I release the parties listed above from any and all liability related to this process of supplying or gathering any information about my suitability for employment.

I also understand that an incomplete application may delay or prevent employment opportunities with Clermont Kidz.  I hereby release Clermont Kidz. as well as those contacted by the Clermont Kidz from any liability or damage which may result from providing or using the information requested.

 

Today’s Dateà

Type in your full Nameà

 *By typing your full name and clicking on (Submit Application), you authorize Clermont Kidz Care to investigate my references, credit, work record, education, performance evaluations, criminal history or any other matters relating to my suitability for employment. 


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