Employment Application Step 1 of 6 16% Northeastern Childcare Services Employment Application Instructions: Please read the instructions before completing the application. All information submitted is subject to verification. A false or misleading statement may result in your disqualification. If you are in need of an accommodation to complete this application, please call for an appointment at the phone number below. Position Title: Date available for work: MM slash DD slash YYYY Full Time Part Time Summer Substitute Summer Employment Internship Personal DataName:* First Middle Last Current Address: Street Address City State / Province / Region ZIP / Postal Code List any other names used if different from given name: Email:* Phone (Home):Phone (Cell): Education and TrainingHighest Grade Completed:* High School Diploma or GED?* College or Universities:Name and Location of School:Sem/Clock Hours Completed:Graduated Y/N:Expected Graduation date:Type of Diploma or Degree:Major/Minor Field of Study: Technical, Vocational, or Business:Name and Location of School:Sem/Clock Hours Completed:Graduated Y/N:Expected Graduation date:Type of Diploma or Degree:Major/Minor Field of Study Transcript and/or Diploma Required At Time of HireLicense/Certification (CDA, CDL, Food handlers, etc.)Date IssuedIssued By (State or Other Authority)License NumberLocation of Issuing Authority (City & State) Special Training:List any special training program or courses you have attended which you feel may add to your qualifications. List course, date and institution (including military training). Course TitleDateGranting Institution SPECIAL SKILLS/QUALIFICATIONS:List special skills or qualifications (not listed above) you possess which you believe further qualify you for the position for which you are an applicant (include computer software, specialized equipment or machines, memberships, areas of expertise for recreation/sport training and instruction). General InformationHave you ever been convicted of a MISDEMEANOR or FELONY and/or placed on probation, fined or given a suspended sentence such as deferred adjudication in court? List all cases other than minor traffic violations.* Yes No Date:Charge:City/State:Disposition:Date:Charge:City/State:Disposition:Have you ever applied to Treasure House Child Development Centers before? Yes No Have you ever worked for Treasure House Child Development Centers before? Yes No What salary or rate of pay do you expect to receive if employed? Employment HistoryIn the space provided below, give your employment history beginning with your present or most recent employer. List each position held (even those with the same employer), including military, part-time, summer and volunteer work. Interns and Volunteers: It is not necessary to complete salary information. Employer: Street Address City State / Province / Region PhoneJob Title: Supervisor: Supervisor's Title: Start Date: Month Day Year End Date: Month Day Year Starting Salary: Final Salary: Briefly Describe the Nature and Duties of your Position:Employer: Street Address City State / Province / Region PhoneJob Title: Supervisor: Supervisor's Title: Start Date: Month Day Year End Date: Month Day Year Starting Salary: Final Salary: Briefly Describe the Nature and Duties of your Position:Employer: Street Address City State / Province / Region PhoneJob Title: Supervisor: Supervisor's Title: Start Date: Month Day Year End Date: Month Day Year Starting Salary: Final Salary: Briefly Describe the Nature and Duties of your Position:Employer: Street Address City State / Province / Region PhoneJob Title: Supervisor: Supervisor's Title: Start Date: Month Day Year End Date: Month Day Year Starting Salary: Final Salary: Briefly Describe the Nature and Duties of your Position: REFERENCES Name: First Phone:Address: Street Address City State / Province / Region Years Known:Relationship: Name: First Phone:Address: Street Address City State / Province / Region Years Known:Relationship: Name: First Phone:Address: Street Address City State / Province / Region Years Known:Relationship: General InformationBy submitting this application and checking 'yes' I certify that I have read and fully understand this form in its entirety and that the information provided is true and complete to the best of my knowledge. I understand that should any statement I have made prove false, misleading, or erroneous, it may result in the rejection of my application or discharge from Northeastern Child Care Services. In submitting this application, I authorize Northeastern Child Care Services to verify all data needed to support this application and to obtain references from my present and past employers. I further understand that this application becomes the property of Northeastern Child Care Services and will not be returned. I also understand that as a condition of employment I will be subject to one or more of the following: initial health assessment, including the results of initial tuberculin skin test, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis, criminal record test, child abuse registry report, clearance information required under CPSL and driving record check. An employment offer received from NCCS is contingent upon information received. Do you agree to the above:* Yes No Date Submitted:* MM slash DD slash YYYY File Submit:Max. file size: 70 MB. THANK YOU FOR YOUR INTEREST IN EMPLOYMENT WITH NORTHEASTERN CHILD CARE SERVICES An equal opportunity employer. Δ
