Employment

 

 
Please print the employee application and mail or drop-off to:     
                   TLC
    3077 Hartford Hwy.
     Dothan, AL 36305

    Attention: Director

 EMPLOYEE APPLICATION

 

Date:________________________

Position: ______________________

Hours available:_________________

                                                         

Name: ______________________________________________________________________

            Last                              First                              Middle   Maiden

Address:_____________________________________________________________________

            Street                           City                  State                            Zip Code

 

Telephone Number: (     )______________ Date of Birth:_____________

Driver’s License Number:______________ Expiration Date:___________

Social Security Number: ________________________

 

EDUCATION:

EDUCATION

SCHOOL/

INSTITUTION

DATES ATTENDED

DIPLOMA/DEGREE/

CERTIFICATE

Elementary

 

 

 

High School

 

 

 

College

 

 

 

Graduate

 

 

 

Other

 

 

 

 

CHILD CARE TRAINING:

Title of course/ Workshop/ Conference

Sponsor

Location

Date(s)

Number of Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYMENT HISTORY:

List in order beginning with your most recent employment.  Attach additional pages if necessary.

Employer

Employer’s Address

Position/Job

Date(s) Worked

Reason for Leaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current or Previous Salary

$______.___ hr

 

 

 

 

REFERENCES:

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.

 

Name:____________________________________________________

            Last                           First                                            Middle

 

Address:__________________________________________________

               Street                                                    City

 

        State                 Zip Code                            Telephone Number

 

Name:____________________________________________________

            Last                           First                                            Middle

 

Address:__________________________________________________

               Street                                                    City

 

        State                 Zip Code                            Telephone Number

 

Name:____________________________________________________

            Last                           First                                            Middle

 

Address:__________________________________________________

               Street                                                    City

 

        State                 Zip Code                            Telephone Number

 

 

Criminal History Background Information Checks:

In accordance with Alabama Law, (Act 2000-775), the criminal history background information check shall be completed on each substitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact with the children or unsupervised access to the children shall be reviewed.

 

You must complete a Mandatory Criminal History Notice Form and a Criminal History Information Consent and Release Form.

 

Current Criminal Charges:

Are there any current criminal charges against you? ________________

If yes, give details.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

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.

 

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.

 

 

Signature                                                                                                                                              Date

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