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:
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EDUCATION |
SCHOOL/ INSTITUTION |
DATES ATTENDED |
DIPLOMA/DEGREE/ CERTIFICATE |
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Elementary |
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High School |
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College |
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Graduate |
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Other |
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CHILD CARE TRAINING:
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Title of course/ Workshop/ Conference |
Sponsor |
Location |
Date(s) |
Number of Hours |
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EMPLOYMENT HISTORY:
List in order beginning with your most recent employment. Attach additional pages if necessary.
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Employer |
Employer’s Address |
Position/Job |
Date(s) Worked |
Reason for Leaving |
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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
