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Employment Application Auburn
Employment Application (Auburn)
Personal Information:
*
Name
First
Last
Maiden Name (if applicable)
*
Address
Street Address
Address Line 2
City
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State
ZIP Code
*
Email Address
Home Phone
Cell Phone
Driver's License Number
Exp Date of Driver's License
*
Are You at least 19 Years or older?
Yes
No
Position Applied For
Date Available
Salary Desired
Full Time or Part Time?
Full Time
Part Time
What Hours/Days are you available?
Are you willing to work overtime?
Yes
No
Are you willing to attend Evening/Weekend Staff Meetings & work 1-2 Saturdays per year?
Yes
No
Do you have Current CPR/First Aid?
Yes
No
EDUCATION:
*
High School/G.E.D.
Dates Attended
Diploma/Degree/Certificate
*
Did you graduate?
Yes
No
College
Dates Attended
Diploma/Degree/Certificate
Type of Diploma or Degree received upon completion
Did you graduate?
Yes
No
Other
Dates Attended
Did you graduate?
Yes
No
Diploma/Degree/Certificate
Type of Diploma or Degree received upon completion
Child Care Training
Title of Course / Workshop / Conference
Sponsor/Location
Dates Attended
Number of Hours
Title of Course / Workshop / Conference
Sponsor/Location
Dates Attended
Number of Hours
Title of Course / Workshop / Conference
Sponsor/Location
Dates Attended
Number of Hours
Title of Course / Workshop / Conference
Sponsor/Location
Dates Attended
Number of Hours
Work Experience
Most recent position first
Company Name
Date From
Date To
Address
Street Address
Address Line 2
City
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
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Mississippi
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Montana
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Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Phone
Salary?
Job Title
Work Performed
Briefly describe your duties, responsibilities and accomplishments while employed
Reason for Leaving
May We Contact For References?
Yes
No
Company Name
Date From
Date To
Address
Street Address
Address Line 2
City
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
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
ZIP Code
Phone
Salary?
Job Title
Work Performed
Briefly describe your duties, responsibilities and accomplishments while employed
Reason For Leaving
May We Contact For References?
Yes
No
Company Name
Date From
Date To
Address
Street Address
Address Line 2
City
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
State
ZIP Code
Phone
Salary?
Job Title
Work Perfomed
Briefly describe your duties, responsibilities and accomplishments while employed
Reason for Leaving
May We Contact For References?
Yes
No
Company Name
Date From
Date To
Address
Street Address
Address Line 2
City
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
State
ZIP Code
Phone
Salary?
Job Title
Work Perfomed
Briefly describe your duties, responsibilities and accomplishments while employed
Reason for Leaving
May We Contact For References?
Yes
No
Criminal History Record
In accordance with Alabama law, (Code of Alabama 1975, Title 38, Chapter 13, effective November 1, 2000), the criminal history background information check shall be completed on each substitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact with the children or unsupervised access to the children shall be reviewed. You must complete a Mandatory Criminal History Notice Form and a Criminal History Information Consent and Release Form. The fee will be payroll deducted. If you previously had a criminal history check done for the Department of Human Resources and the required information is on file, it is not necessary to complete a fingerprint criminal history check.
Have you ever been convicted of any criminal offense other than a minor traffic violation?
Yes
No
If yes, give details below
Clearance of State Central Registry on Child Abuse/Neglect: A completed REQUEST FOR CLEARANCE OF STATE CENTRAL REGISTRY ON CHILD ABUSE/NEGLECT (DHR-DFC-1598) shall be obtained for each caregiver, substitute, volunteer, domestic worker, and any other person who has contact with the children or unsupervised access to the children.
References
List at least three persons who are not related to you by blood, marriage, or adoption, to be contacted as references. At least one must be a former employer. Addresses must be complete and accurate.
*
Name
Relationship
Address
Street Address
Address Line 2
City
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
State
ZIP Code
*
Phone
*
Occupation
*
Years Known
*
Name
Relationship
Address
Street Address
Address Line 2
City
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
State
ZIP Code
Phone
*
Occupation
*
Years Known
Name
Relationship
Address
Street Address
Address Line 2
City
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
State
ZIP Code
*
Phone
*
Occupation
*
Years Known
Emergency Contact Information
Please list at least two people to contact in case of emergency
Name
Relationship
Address
Street Address
Address Line 2
City
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
State
ZIP Code
Phone
Phone
Name
Relationship
Address
Street Address
Address Line 2
City
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
State
ZIP Code
Phone
Phone
By signing this form, I am affirming that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions in my application or in the interview may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. I authorize persons, schools, my current employer (if applicable) and previous employers and organizations names in this applicant (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision. In consideration of my employment, I agree to confirm to the policies and rules of this company and further agree and understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself.
*
Applicant Signature
Please use your initials as your signature
*
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