Employment Application

General Information

Name:*

First

Last

Position Applied for:*

Type of Employment Desired:*

Full time
Part time
Temporary
Seasonal
Full time internship
Part time internship

Referral Source:*

If other, please name source:

Contact Information

Address:*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email- must be checked regularly:*

Phone Number used most often:*

If necessary, the best time to call you is:*

May we contact you at work?*

Yes
No
N/A

If yes, what is your work number and best time to call?

Time

:

AM/PM

If you are under 18, can you furnish a work permit?*

Yes
No
N/A

Have you filed an application with Girls Place, Inc before?*

Yes
No

If yes, please provide date filed:

mm/yyyy

Have you been employed at Girls Place, Inc before?*

Yes
No

From:

To:

Availability

What days and times are you available?

Monday:*

Tuesday:*

Wednesday:*

Thursday:*

Friday:*

Date Available to Begin Work:*

Personal Information

Are you legally eligible for employment in this country? (Proof of U.S. citizenship will be required upon employment.)*

Yes
No

Are you on lay-off and subject to recall?*

Yes
No

Will you relocate if job requires it?*

Yes
No

Will you travel if job requires it?*

Yes
No

Are you able to meet the attendance requirements of this position?*

Yes
No

Will you work overtime if job requires it?*

Yes
No

Have you ever been bonded?*

Yes
No

Have you ever worked at a job where your employer had insurance to protect their clients from any damage you may cause (intentionally or unintentionally)?*

Yes
No

Have you ever held a child care license with the Department of Children and Families or been registered to provide child care in your own home?

Yes
No

Have you ever worked in a child care facility before?*

Yes
No

While employed in a child care program, have you ever been the subject of disciplinary action, or been the part responsible for a child care facility receiving an administrative fine or other disciplinary action?*

Yes
No
N/A

If yes, please explain:

Driver's License Number (if job related):

State License Held In:

Employment History

List your last four (4) employers, assignments, or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in the comments section below. Please do not put “see resume” in this section.

#1

Employer:

Job Title:

Phone Number:

Address:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Start Date:

End Date:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Please summarize the nature of the work performed and job responsibilities:

Immediate Supervisor's Name and Title:

Immediate Supervisor's Email Address:

Reason for Leaving:

May we contact for reference?

Yes
No
After Interview

#2

Employer:

Job Title:

Phone Number:

Address:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Start Date:

End Date:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Please summarize the nature of the work performed and job responsibilities:

Immediate Supervisor's Name and Title:

Immediate Supervisor's Email Address:

Reason for Leaving:

May we contact for reference?

Yes
No
After Interview

#3

Employer:

Job Title:

Phone Number:

Address:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Start Date:

End Date:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Please summarize the nature of the work performed and job responsibilities:

Immediate Supervisor's Name and Title:

Immediate Supervisor's Email Address:

Reason for Leaving:

May we contact for reference?

Yes
No
After Interview

#4

Employer:

Job Title:

Phone Number:

Address:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Start Date:

End Date:

Starting Hourly Rate/Salary:

Final Hourly Rate/Salary:

Please summarize the nature of the work performed and job responsibilities:

Immediate Supervisor's Name and Title:

Immediate Supervisor's Email Address:

Reason for Leaving:

May we contact for reference?

Yes
No
After Interview

Educational Background (if job related)

List the last three (3) schools attended, starting with most recent.

#1

School Name:

Number of Years Completed:

Graduated?

Yes
No

Degree/Diploma Received:

Grade Point Average or Class Rank:

#2

School Name:

Number of Years Completed:

Graduated?

Yes
No

Degree/Diploma Received:

Grade Point Average or Class Rank:

#3

School Name:

Number of Years Completed:

Graduated?

Yes
No

Degree/Diploma Received:

Grade Point Average or Class Rank:

Foreign Languages

List any foreign language(s) you know and check the box that describes your skill level. If English is your primary and only language, please skip ahead to references.

Language #1:

Speak some
Speak fluently
Read
Write

Language #2:

Speak some
Speak fluently
Read
Write

Language #3:

Speak some
Speak fluently
Read
Write

Language #4:

Speak some
Speak fluently
Read
Write

References

List name and telephone number of three business/work references who are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references who are not related to you.

Reference #1

Name:

First

Last

Phone:

Number of Years Known:

Reference #2

Name:

First

Last

Phone:

Number of Years Known:

Reference #3

Name:

First

Last

Phone:

Number of Years Known:

Additional

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability, or other protected status.)

Organization & Office(s) held:

Skills and Qualifications: Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work with our company.*

List special accomplishments, publications, and awards. (Exclude information which would reveal sex, race, religion, national origin, age, color, disability, or other protected status.)

List any additional information you would like us to consider.

Attachments

Please attach your Resume here. Only Word '.doc' or Adobe '.pdf' files will be accepted.

Max. file size: 100 MB.

If you would like to upload a cover letter or other document, you may attach one here.

Max. file size: 100 MB.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the Employer's service if I have been employed. I give the Employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporation, or organizations for furnishing such information. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application. I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make and assurances to the contrary. By typing my name below, I hereby agree to abide by the rules and regulations of Girls Place, Inc., as they relate to my possible employment and understand that this will serve as my digital signature for this application.*

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