Application for Employment

General Information

Name *

Email *

Phone *

Are you *Under 1818 or Older

Address *

City *

State *

Zip Code *

Are you known to schools/references by another name? *NoYes

Are you authorized to work in the United States? *YesNo

Have you ever been employed with Ebenezer Child Care Centers, Inc. before? *YesNo

If yes — When? What position? What center?

Emergency Contact

In case of an emergency, whom should we notify? *

Relationship *

Phone (Emergency Contact) *

Address (Emergency Contact) *

Other Background

Have you ever been convicted of a crime or pleaded no contest for any offense or violation other than minor traffic violations? *YesNo

If yes, explain: (Note: Convictions are not an automatic bar to employment.)

Do you have any pending criminal charges against you? *YesNo

If yes, describe

Are you on layoff subject to recall? *YesNo

Are you able, with or without accommodation, to perform the essential functions of the job for which you have applied? *YesNo

Education

High School

High School — Name & Address *

High School — Course of Study

High School — Number of Years Completed

High School — Did You Obtain Degree? *YesNo

College

College — Name & Address *

College — Course of Study

College — Number of Years Completed

College — Did You Obtain Degree? *YesNo

Graduate School

Graduate School — Name & Address

Graduate School — Course of Study

Graduate School — Number of Years Completed

Graduate School — Did You Obtain Degree? *YesNo

Other

Other — Name & Address

Other — Course of Study

Other — Number of Years Completed

Other — Did You Obtain Degree? *YesNo

Other Education

Please list all child care courses taken. (You will be asked to provide certificates of completion.)

What additional training would you like in Early Childhood Education?

Employment Experience

Employer #1

Employer (1) — Name *

Employer (1) — Address *

Employer (1) — Phone *

Employer (1) — Job Title *

Employer (1) — Supervisor *

Employer (1) — Dates Employed *

Employer (1) — Reason for Leaving *

Employer (1) — Responsibilities *

Employer #2

Employer (2) — Name

Employer (2) — Address

Employer (2) — Phone

Employer (2) — Job Title

Employer (2) — Supervisor

Employer (2) — Dates Employed

Employer (2) — Reason for Leaving

Employer (2) — Responsibilities

Employer #3

Employer (3) — Name

Employer (3) — Address

Employer (3) — Phone

Employer (3) — Job Title

Employer (3) — Supervisor

Employer (3) — Dates Employed

Employer (3) — Reason for Leaving

Employer (3) — Responsibilities

Employer #4

Employer (4) — Name

Employer (4) — Address

Employer (4) — Phone

Employer (4) — Job Title

Employer (4) — Supervisor

Employer (4) — Dates Employed

Employer (4) — Reason for Leaving

Employer (4) — Responsibilities

Preferences

Position Desired (Job Title) *

Preferred Status *FullTimePartTimeSummer Only

Hours Desired Per Week *

Date Available To Begin *

Preferred Work Location(s) *

Age Group of children you prefer to work with *

Additional Information

Please list any additional job-related inservices, continuing education courses or workshops that you have attended. Also include special qualifications or skills that you possess:

References

Reference #1

Reference (1) — Name *

Reference (1) — Position/Company *

Reference (1) — Relationship to Applicant *

Reference (1) — Address *

Reference (1) — Phone *

Reference #2

Reference (2) — Name

Reference (2) — Position/Company

Reference (2) — Relationship to Applicant

Reference (2) — Address

Reference (2) — Phone

Reference #3

Reference (3) — Name

Reference (3) — Position/Company

Reference (3) — Relationship to Applicant

Reference (3) — Address

Reference (3) — Phone

Reference #4

Reference (4) — Name

Reference (4) — Position/Company

Reference (4) — Relationship to Applicant

Reference (4) — Address

Reference (4) — Phone

Read Carefully and Sign

I hereby authorize Ebenezer Child Care Centers, Inc. to investigate my background, and verify all information which I provided in this application or otherwise. I release Ebenezer and its subsidiaries from any liability arising out of their investigation of my application for employment. I further authorize my past employers to share with Ebenezer any information concerning my employment that may be relevant to making an employ- ment decision, and release all parties from any liability for damage that may result from furnishing this information. I certify that this information and any supporting documents that I have provided or will provide to Ebenezer, whether oral or written, is correct to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of fact will constitute grounds for the rejection of my application, withdrawal of an offer of employment, or immediate dismissal from employment with Ebenezer regardless of when the falsification is discovered.

I have read and understand each of the statements above, and sign this form in return for consideration for employment in the job specified.

If you agree to these terms, type “I Agree” followed by your initials: *