Application for Employment Step 1 of 4 25% PERSONAL INFORMATIONLast Name(Required)First Name(Required)Middle Name/InitialAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Other PhoneEmail(Required) Date of Application(Required) MM slash DD slash YYYY Position Applied ForHave you ever been convicted of a felony?(Required) Yes No EDUCATIONHigh School(Required)Degree/Diploma/Highest Year Completed(Required)College/UniversityCourse of StudyDegree/Diploma/Highest Year CompletedCollege/UniversityCourse of StudyDegree/Diploma/Highest Year CompletedCollege/UniversityCourse of StudyDegree/Diploma/Highest Year CompletedREFERENCES – NON-RELATIVESName(Required)Telephone(Required)Relationship(Required)Years Known(Required)This field is hidden when viewing the formVerifiedName(Required)Telephone(Required)Relationship(Required)Years Known(Required)This field is hidden when viewing the formVerifiedName(Required)Telephone(Required)Relationship(Required)Years Known(Required)This field is hidden when viewing the formVerified CERTIFICATIONS/SPECIAL TRAINING:Childcare training you have completed in the last three years (such as First Aid, CPR, CDA, etc.)(Required)LICENSING:Do you currently have a driver’s license?(Required) Yes No C.D.L.?(Required) Yes No A “for hire” endorsement?(Required) Yes No If no to above, would be willing to obtain a driver’s license?(Required) Yes No C.D.L.?(Required) Yes No A “for hire” endorsement?(Required) Yes No WORK HISTORY List childcare experience before other work experience, with most recent first.Company/Business Name(Required)Address(Required)Telephone(Required)Supervisor(Required)Job Title(Required)Start Date(Required)End Date(Required)How long in this position?(Required)# Hours Per Week(Required)Salary(Required)Reason for leaving?(Required)May we contact employer?(Required) Yes No Duties(Required)Company/Business Name(Required)Address(Required)Telephone(Required)Supervisor(Required)Job Title(Required)Start Date(Required)End Date(Required)How long in this position?(Required)# Hours Per Week(Required)Salary(Required)Reason for leaving?(Required)May we contact employer?(Required) Yes No Duties(Required)Company/Business Name(Required)Address(Required)Telephone(Required)Supervisor(Required)Job Title(Required)Start Date(Required)End Date(Required)How long in this position?(Required)# Hours Per Week(Required)Salary(Required)Reason for leaving?(Required)May we contact employer?(Required) Yes No Duties(Required)Note: If hired for employment by Fannie Battle Day Home For Children, Inc. , you must obtain a medical exam and supply a recent TB test. You are required to assume responsibility for any exams, tests or related costs.Disclosure(Required) I agreeI 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 investigation 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 should be employed, and/or criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications.Signature of Applicant(Required)Printed name of Applicant(Required)Date(Required) MM slash DD slash YYYY This field is hidden when viewing the formDo not write below this lineThis field is hidden when viewing the formInterviewed by:This field is hidden when viewing the formDateThis field is hidden when viewing the formCommentsThis field is hidden when viewing the formIf referred by a current family or employee, list their name herePhoneThis field is for validation purposes and should be left unchanged.
