Employment Application Growing Room One

Personal Information:

* Name

First

Last

Maiden Name (if applicable)

* Address

Street Address

Address Line 2

City

State

ZIP Code

* Email Address

Home Phone

Cell Phone

Driver's License Number

Exp Date of Driver's License

* Are You at least 18 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

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

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

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

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

State

ZIP Code

* Phone

* Occupation

* Years Known

* Name

Relationship

Address

Street Address

Address Line 2

City

State

ZIP Code

Phone

* Occupation

* Years Known

Name

Relationship

Address

Street Address

Address Line 2

City

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

State

ZIP Code

Phone

Name

Relationship

Address

Street Address

Address Line 2

City

State

ZIP Code

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

* Date

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