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Elementary School:
Dates Attended:
Diploma/Degree/Certificate |
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High School:
Dates Attended:
Diploma/Degree/Certificate |
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College:
Dates Attended:
Diploma/Degree/Certificate |
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Graduate School:
Dates Attended
Diploma/Degree/Certificate
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Title of Course/Workshop/Conference:
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Title of Course/Workshop/Conference:
Sponsor:
Location:
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Employment History:
List in order beginning with your most recent employment. |
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| Employer 4: |
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References:
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List at least three persons who are not related to you by blood, marriage, or adoption to be contacted as references. At least one must be a former employer. Addresses must be complete and accurate. |
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| Criminal History Background Information Check: |
In accordance with Alabama Law (Act 2000-775), the criminal history background information check shall be completed on each subsitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact wiht the children or unspervised access to the children shall be reviewed.
You must complete a Mandatory Criminal History Notice Form and Criminal History Information Consent and Release Form. |
Current Criminal Charges:
Are there any current criminal charges against you? |
YesNo |
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Clearance of State Central Registry on Child Abuse/Neglect:
A completed Request for Clearance of State Central Registry on Child Abuse/Neglect shall be obtained for each caregiver, substitute, volunteer, domestic worker, and any other person who has contact with the children or unsupervised access to the children. |
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| Date: |
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| Applicant Signature: |
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By signing this form, I am affirming that the above statements I have made are true and factual to the best of my knowledge; and I am granting permission for all persons, organizations, or agencies listed above to be contacted for information regarding my background.
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