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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?
Best Time To Call You
Mornings
Early Afternoon
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Early Evening
Are You 21 or older:
(Required)
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No
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
No
Name:
Unit:
Relationship:
Have you ever been employed by this facility?
(Required)
Yes
No
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
No
If yes, explain
Have you ever been convicted of, or pled guilty to a crime? (excluding misdemeanor traffic violations)
(Required)
Yes
No
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
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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
No
SCM CERTIFIED
(Required)
Yes
No
FA/AED CERTIFIED
(Required)
Yes
No
MED AID CERTIFIED
(Required)
Yes
No
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
No
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
No
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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