Child360

Application for Employment

Child360 is an Equal Opportunity Employer. Child360 will not discriminate against applicants or employees on the basis of race, color, religion, sex, pregnancy, sexual orientation, national origin, age, marital status, physical or mental disability, medical condition, citizenship, veteran status, or any other classification protected by applicable federal, state, or local law.

Please complete the entire application using blue or black ink. Please print legibly.

Applicant Information

Full Name: /
Date:

Last

/

First

/

M.I.

Address:

Street Address

/

Apartment/Unit #

City

/

State

/

ZIP Code

Home Phone: / ( ) /
Email

Cell Phone: (____)______

Date Available: /
Social Security No.:
/ _____ /
Desired Salary:
/ $
Position Applying for:
How were you referred toChild360
or how did you hear of this position?:
Can you perform the essential functions of the position for which you are applying with or without a reasonable accommodation? YES NO ______

In accordance with applicable law, all persons hired will be required to verify their identity and eligibility to work in the United States by completing the required employment authorization verification documentation.

Are you authorized to work in the U.S.? / YES / NO /
Do you have a valid driver license? / YES / NO /
Have you ever worked for First5 LA or Child360? / YES / NO /
If yes, when?
Do you have relatives working for First5 LA or Child360? / YES / NO /
If yes, who?
/ ______

Education

High School: /
Address:
From: /
To:
/
Did you graduate?
/ YES / NO /
Diploma::
College: /
Address:
From: /
To:
/
Did you graduate?
/ YES / NO /
Degree:
Other: /
Address:
From: /

To:

/

Did you graduate?

/ YES / NO /

Degree:

Previous Employment

Company: /

Phone:

Address: /

Supervisor:

Job Title: /

Starting Salary:

/ $ /

Ending Salary:

/ $
Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO
Company: /

Phone:

Address: /

Supervisor:

Job Title: /

Starting Salary:

/ $ /

Ending Salary:

/ $
Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO
Company: /

Phone:

Address: /

Supervisor:

Job Title: /

Starting Salary:

/ $ /

Ending Salary:

/ $
Responsibilities:
From: /

To:

/

Reason for Leaving:

May we contact your previous supervisor for a reference? / YES / NO

References

Please list three professional references.

Full Name: /

Relationship:

Company: /

Phone:

Address:
Full Name: /

Relationship:

Company: /

Phone:

Address:
Full Name: /

Relationship:

Company: /

Phone:

Address:

Disclaimer and Signature

I certify that all of the information furnished on this application is true, complete, and correct. I understand and agree that any falsification, misrepresentation or omission of fact, either on this application, or during the pre-hire process may make me ineligible for employment with Child360.

Child360 is an at-will employer, and I understand and agree that if offered employment with Child360, my employment is at-will.

The Immigration Reform and Control Act of 1986 states that employers must require all persons hired to submit documents to the employer showing their identity and their right to be lawfully employed in the United States. It also requires the employee to completed and sign a government form to this effect. If you are hired by Child360, you will need to furnish documents for inspection that verify your identity, and indicate that you are legally permitted to work in the United States. These documents must be provided within three (3) working days of employment. If the original documents are not available, you must submit proof that you have applied for the required documents. A list of acceptable documents is listed on the verification form you will be asked to complete.

By signing this application form, I hereby authorize Child360 and its agents to investigate the statements made on this application. I understand that Child360 may investigate my background that may include my education, previous employments, criminal history and driving record. The purpose of this background check is to verify the statements I have made on the application for employment, and to help determine my qualifications for employment at Child360.

I have read and understood the above statements.

Signature: /

Date:

Print Name: ______

3 Child360 Employment Application 2017