Employment Application

Step 1 of 5

EDUCATION
High School or Last Grade Completed
Name of School
Address of School
Street Address City State / Province / Region ZIP / Postal Code
Course of Study
Number of Years Completed
Degree/Diploma
College or Technical School
Name of School
Address of School
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Course of Study
Number of Years Completed
Degree/Diploma
Other Schooling or Training
Name of School
Address of School
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Course of Study
Number of Years Completed
Degree/Diploma
Licenses
List all professional licenses and certifications
Have any of your licenses or certifications ever been suspended or revoked?*
- Yes
- No
If yes, please explain:
Have you ever been disciplined by any licensing authority (whether governmental or non-governmental)?*
- Yes
- No
If yes, please explain:

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Record of Employment
Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job-related volunteer work, if applicable. Indicate number of employees supervised. Use a separate block to describe each position or gap in employment. If needed, attach additional sheets, using the same format as on the application. All information in this section must be completed.
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Title
Supervisor
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Begining Salary
Ending Salary
Duties
Reason for Leaving
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Title
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Begining Salary
Ending Salary
Duties
Reason for Leaving
Employer
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position Title
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Begining Salary
Ending Salary
Duties
Reason for Leaving
Has any employment you have held ended involuntarily?
- Yes
- No
If yes, please explain

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(Please read this statement carefully before signing): I certify that the answers and information given by me in this application and in my submitted resume and cover letter are true and correct to the best of my knowledge and understanding. I have answered each question completely. I understand that misleading or false statements or omissions on this application or in my resume and cover letter shall be grounds for my disqualification from consideration for employment or, if employed, for dismissal from employment. I authorize investigation of all statements contained in this application and in my submitted resume and cover letter. I authorize Jack and Jill Children’s Center and/or its designees to contact the references, licensing authorities, educational institutions, and employers listed on this application and in my resume to obtain any information concerning my previous and current employment and any pertinent information that they may have about me; and I hereby release Jack and Jill Children’s Center and/or its designees and any prior and current employers or references from all liability for any damage that may result from the use of such information; and I further agree not to pursue a claim against any of them for any reason arising out of or pertaining to information as provided or used. I understand and agree that if I am hired, my employment is at will and for no definite period of time, and may be terminated by Jack and Jill Children’s Center or me at any time, with or without cause, and without any prior notice. I understand and agree that no representative of Jack and Jill Children’s Center has authority to enter into any agreement with me for employment for any specified period of time, or to waive or make any agreement to contrary to the provisions of this document, unless it is writing and signed by the Executive Director. I understand and agree that if I am hired, I must abide by the policies and procedures of Jack and Jill Children’s Center. I understand that any offer of employment is conditioned on my ability to produce the required documentation to verify my identity and U.S. citizen status or my legal right to work in the United States. I state that I have never worked at a child care facility that has, during the term of my employment (i) had its license denied, revoked, or suspended in any state or jurisdiction, or (ii) been the subject of disciplinary action, or (iii) received a fine(s), while I was employed in the child care facility. I certify and acknowledge that I have read the above statement and agree and understand it.
Signature of Applicant*
Date Signed*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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Employment Application

Step 1 of 5

High School or Last Grade Completed

College or Technical School

Other Schooling or Training

Licenses

Record of Employment

Work-Related References

Jack and Jill Center

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