Employment Application Berlin

Personal Information:

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone

Cell Phone

Are You 18 Years or Older?*

YES
NO

Emergency Contact:

Name

First Last

Relationship

Home Phone

Work Phone

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POSITION APPLIED FOR*

DATE AVAILABLE*

SALARY DESIRED

ARE YOU LOOKING FOR FULL-TIME OR PART-TIME (CHECK ALL THAT APPLY)*

Full-Time
Part-Time

WHAT HOURS/DAYS ARE YOU AVAILABLE?*

ARE YOU WILLING TO WORK OVERTIME?*

Yes
No

ARE YOU WILLING TO WORK OCCASIONAL SATURDAYS?*

Yes
No

ARE YOU WILLING TO ATTEND EVENING/WEEKENDS STAFF MEETINGS?*

Yes
No

DO YOU HAVE A CURRENT CPR/FIRST AID?*

Yes
No

ARE YOU WILLING TO OBTAIN AND MAINTAIN CURRENT CPR/FIRST AID?*

Yes
No

ARE YOU WILLING TO OBTAIN AND MAINTAIN THE TRAINING REQUIRED BY THE DEPARTMENT OF HUMAN RESOURCES?*

Yes
No

DO YOU HAVE RELATIVES EMPLOYED BY THIS COMPANY?*

Yes
No

IF YES, GIVE NAME AND RELATIONSHIP

SINCE REACHING AGE 18 YEARS, HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION?*

Yes
No

IF YES, GIVE DETAILS AND DISPOSITION OF THE CASE

CAN YOU PERFORM ALL THE ESSENTIAL FUNCTIONS FOR THE JOB FOR WHICH YOU ARE APPLYING WITH REASONABLE ACCOMMODATIONS?*

Yes
No

HAVE YOU EVER BEEN SHOWN BY CREDIBLE EVIDENCE, e.g., A COURT ORDER OR JURY, A DEPARTMENT INVESTIGATION OR OTHER RELIABLE EVIDENCE, TO HAVE ABUSED, NEGLECTED, OR DEPRIVED A CHILD OR ADULT TO HAVE SUBJECTED ANY PERSON TO SERIOUS INJURY AS A RESULT OF INTENTIONAL GROSSLY NEGLECT MISCONDUCT?*

Yes
No

IF YES, EXPLAIN

EDUCATION:

HIGH SCHOOL*

Years Completed*

DID YOU GRADUATE?*

Yes
No

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COLLEGE

Years Completed

DID YOU GRADUATE?

Yes
No

DEGREE?

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OTHER

Years Completed

DID YOU GRADUATE?

Yes
No

DEGREE?

HAVE YOU EVER RECEIVED ANY DHR-APPROVED CHILD CARE TRAINING WITHIN THE PAST YEAR?*

Yes
No

IF YES, WHAT?

Employment History

Must Account for the Full Past 10 Years, Beginning with the Most Current

Employer

Date From

Date To

Work Performed

Address

Job Title

Starting Salary

Final Salary

Supervisor and Telephone Number

Reason for Leaving

May We Contact For References?

Yes
No

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Employer

Date From

Date To

Work Performed

Address

Job Title

Starting Salary

Final Salary

Supervisor and Telephone Number

May We Contact For References?

Yes
No

Reason for Leaving

May We Contact For References?

Yes
No

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Employer

Date From

Date To

Work Performed

Address

Job Title

Starting Salary

Final Salary

Supervisor and Telephone Number

Reason for Leaving

May We Contact For References?

Yes
No

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DRIVER'S LICENSE: IF YOU ARE APPLYING FOR A CLASSROOM TEACHER POSITION OR VAN DRIVER POSITION, YOU MAY BE REQUIRED TO DRIVE OR TRANSFER CHILDREN ON COMPANY BUSINESS.

DO YOU HAVE A VALID DRIVER'S LICENSE?*

Yes
No

Driver's License #*

A Good Driving Record is Required

Personal References

(NOT RELATIVES OR EMPLOYEES) WHO ACQUAINTED WITH YOUR WORK HISTORY. (MUST HAVE KNOWN AT LEAST ONE YEAR)

Name

First Last

Years Known

Home Address

Home Phone

Occupation*

Work Address

Work Phone

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Name

First Last

Years Known

Home Address

Home Phone

Occupation*

Work Address

Work Phone

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Name

First Last

Years Known

Home Address

Home Phone

Occupation*

Work Address

Work Phone

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I AFFIRM 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 SIGNIFICATION 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 APPLICATION (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 CONFORM 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.

Date

Applicant Signature

Please use your initials as your signature

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