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Employment Application
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UCCLC ULA Employment Application
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Full Name
*
First
Middle
Last
Name
Job Applying for
Employment Desired
Nature of Work
Full time
Part time
Temporary
Salary Desired
Date Available
Date of Birth
Street Address
Personal
Apartment/Unit #
City
State
ZIP
Phone
E-mail Address
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
If hired, can you furnish proof of eligibility?
Yes
No
Are you 18 years or older?
Yes
No
Can you perform the essential function of the position for which you are applying?
Yes
No
Have you ever worked or attended school under another name?
Yes
No
If yes, give details.
Have you ever worked for this organization?
Yes
No
If yes, when?
Have you ever applied here before?
Yes
No
If yes, when?
Are you presently employed?
Yes
No
If yes, may we contact your current employer for a reference?
Yes
No
Have you ever been fired or asked to resign from a job?
Yes
No
Have you ever been convicted of a felony violation?
Yes
No
If yes, give details.
If employed by us, do you expect to be employed elsewhere?
Yes
No
If yes, give details.
High School or GED
Education
Address
From: - To:
Did you graduate?
Yes
No
Degree
Vocational or Technical
Address
From: - To:
Did you graduate?
Yes
No
Degree
College or University
Address
From: - To:
Did you graduate?
Yes
No
Degree
Graduate School
Address
From: - To:
Did you graduate?
Yes
No
Degree
Other
Address
From: - To:
Did you graduate?
Yes
No
Degree
Do you have other skills or training that would be helpful for the job? If yes, please explain.
Name of Employer
Please list your ten year employment history starting with the current or most recent employer. A job offer may be contingent on acceptable references from employers. Please explain gaps in employment.
Phone
Street Address
Apartment/Unit #
City
State
ZIP
Supervisor’s Name
Title
Phone
Email Address
Job Title
Ending Salary
Responsibilities
From: - To:
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Name of Employer
Please list your ten year employment history starting with the current or most recent employer. A job offer may be contingent on acceptable references from employers. Please explain gaps in employment.
Phone
Street Address
Apartment/Unit #
City
State
ZIP
Supervisor’s Name
Title
Phone
Email Address
Job Title
Ending Salary
Responsibilities
From: - To:
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes
No
Organization Name
Volunteer Activities and Professional Memberships
Title
Responsibilities
Years Active
Contact Person
Telephone Number
Organization Name
Title
Responsibilities
Years Active
Contact Person
Telephone Number
Have you attended/completed any child care training courses?
Yes
No
If yes, list
Do you have a valid driver’s license?
Yes
No
If yes, give license number and class of license
Have you had CPR training within the past two years?
Yes
No
If yes, give expiration date
Have you had first aid training within the past three years?
Yes
No
If yes, give expiration date
I hereby certify that all the information provided in this employment application is true and complete. I understand that false information or the omission of information may disqualify my candidacy and may be grounds for termination. I further understand that I am applying to a Drug Free Workplace and may be required to submit to testing for the presence of drugs as a condition for employment.
Yes
Submit
The information you provided here is secured.