2nd Judicial Circuit

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Your Personal Information

Your Name

First Last

Any Previous Names?(Required)

Yes

If yes, identify all other names including maiden name

Your Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone

Date Available for Work(Required)

MM slash DD slash YYYY

Best Time To Call You

When is the best time for us to reach you via telephone?

Are You 21 or older:(Required)

Yes

Check all you are applying for:(Required)

Full Time

Part Time

Position You're Applying For

Check all units you are interested in working:

Residential

Detention

Juvenile Office

Any

Shift Preference:

7a -3p

3p -11p

11p – 7a

Any

List days of the week and times available to work:

MM slash DD slash YYYY

Are You a U.S. Citizen Or An Alien Legally Authorized To Work In The United States?(Required)

Yes

Name:

Unit:

Relationship:

Have you ever been employed by this facility?(Required)

Yes

When?

MM slash DD slash YYYY

Have you ever been listed as a perpetrator in a report of abuse or neglect of children or adults in this or any other state of the United States?(Required)

Yes

If yes, explain

Have you ever been convicted of, or pled guilty to a crime? (excluding misdemeanor traffic violations)(Required)

Yes

If yes, explain

If you answer is “yes” to the above you will not automatically be disqualified from employment Consideration, except as required by state or federal law.

EDUCATION

NAME AND ADDRESS OF SCHOOL

COURSE OF STUDY

CHECK LAST YEAR COMPLETED

DID YOU GRADUATE

LIST DIPLOMA OR DEGREE

OTHER Business College or Special Courses: (Include Special Military Training, Post Graduate and Nursing)

AREA(S) OF SPECIALIZATION OF MAJOR INTEREST:

CPR CERTIFIED(Required)

Yes

SCM CERTIFIED(Required)

Yes

FA/AED CERTIFIED(Required)

Yes

MED AID CERTIFIED(Required)

Yes

PROFESSIONAL LICENSE(Required)

CURRENTLY LICENSED

ELIGIBLE FOR LICENSED

CURRENTLY REGISTERED

ELIGIBLE FOR REGISTRATION

N/A

STATE:

TYPE:

DATE:

NO:

LICENSE OR REGISRATION EVER SUSPENDED, REVOKED OR ON PROBATION?(Required)

Yes

N/A

IF YES, EXPLAIN:

PROFESSIONAL CERTIFICATIONS(Required)

CURRENTLY CERTIFIED

ELIGIBLE FOR CERTIFICATION

N/A

STATE:

TYPE:

DATE:

PROVIDE INFORMATION REGARDING PREVIOUS EMPLOYMENT FOR THE LAST FIVE (5) YEARS BEGINNING WITH MOST RECENT EMPLOYER – ADDITIONAL SHEETS MAY BE ATTACHED

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUPERVISOR’S NAME:

SALARY (Hr/Mo/Yr):

JOB TITLE:

EMPLOYER:

PHONE NUMBER:

ADDRESS:

DUTIES:

REASON FOR LEAVING:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUPERVISOR’S NAME:

SALARY (Hr/Mo/Yr):

JOB TITLE:

EMPLOYER:

PHONE NUMBER:

ADDRESS:

DUTIES:

REASON FOR LEAVING:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUPERVISOR’S NAME:

SALARY (Hr/Mo/Yr):

JOB TITLE:

EMPLOYER:

PHONE NUMBER:

ADDRESS:

DUTIES:

REASON FOR LEAVING:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUPERVISOR’S NAME:

SALARY (Hr/Mo/Yr):

JOB TITLE:

EMPLOYER:

PHONE NUMBER:

ADDRESS:

DUTIES:

REASON FOR LEAVING:

FROM:

MM slash DD slash YYYY

TO:

MM slash DD slash YYYY

SUPERVISOR’S NAME:

SALARY (Hr/Mo/Yr):

JOB TITLE:

EMPLOYER:

PHONE NUMBER:

ADDRESS:

DUTIES:

REASON FOR LEAVING:

VOLUNTEER/SERVICE EXPERIENCE AND SKILLS

Have you volunteered your time or service?(Required)

Yes

Where?

Briefly describe your skills and experience working with youth and families (coaching/daycare, etc.)

REFERENCES

LIST AT LEAST THREE (3) REFERENCES WHO ARE NOT REALATIVES OR EMPLOYERS:

NAME

RELATIONSHIP

TITLE

COMPANY NAME AND ADDRESS

TELEPHONE/ E-MAIL

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