Employment Application
Rev. 2/28/11
Homes of Hope for Children, Inc.
PO Box 18496
Hattiesburg, Mississippi39404
(769) 456-7021 Fax: (769) 456-7022
Position of: □ Houseparent □ Relief Staff □Counselor □Administration
Houseparent applicants: Each person needs to fill out an application. (We should receive two per couple.)
Date of Application: ______
Name: ______
Last First Middle
Present Address: ______
Street City State Zip
Daytime Phone Number: ______(Home / Work)
Nighttime Phone Number: ______(Home / Work)
Social Security Number: ______
*Date of Birth: ______U.S. Citizen: □ Yes □ No
Driver’s License Number: ______State: ______
Emergency Contact: ______
Name Phone Number Relationship
If hired, on what date could you begin work? ______
*Name and address of church you presently attend: ______
*Name and office phone number of your pastor: ______
*Number of years you have attended this church: ______
For Houseparent and Counselor Applicants Only:
Name of Spouse: ______
Date of Marriage: ______
Sexes and Ages of Children: ______
*Applicants are not required to provide this information under Department of Labor guidelines.
Education
Name/Address of School Years Attended Diploma/Degree Major/Minor
(From To)
High School
College/University
College/University
Other Schooling
Professional Certificates of Licenses held: ______
Subjects or Special Studies: ______
Extra-curricular Activities: ______
Have you had any education or training in residential group child care and/or child welfare? ______
If yes, explain: ______
For Clerical Applicants: Typing Speed ______Computer Skills: ______
Court and Credit Data
If you have been convicted for an offense other than minor traffic violations, give date, offense, court,
and sentence: ______
Has your credit rating (including spouse) ever been considered unsatisfactory, or have you ever been
refused credit? ______If yes, give dates, name of creditors, and circumstances: ______
______
Please note: Further in the interview process, we may obtain on all applicants: 1) Credit Record, 2) Driving Record, and 3) Criminal Background Check.
Employment History
(Last five employers or ten years)
Present or last employer ______Position ______
Address ______
Supervisor’s Name ______Supervisor’s Phone ______
Date Employed ______Date Left ______
Beginning Salary ______Ending Salary ______
Major Accomplishments ______
______
______
Previous employer ______Position ______
Address ______
Supervisor’s Name ______Supervisor’s Phone ______
Date Employed ______Date Left ______
Beginning Salary ______Ending Salary ______
Major Accomplishments ______
______
______
Previous employer ______Position ______
Address ______
Supervisor’s Name ______Supervisor’s Phone ______
Date Employed ______Date Left ______
Beginning Salary ______Ending Salary ______
Major Accomplishments ______
______
______
Previous employer ______Position ______
Address ______
Supervisor’s Name ______Supervisor’s Phone ______
Date Employed ______Date Left ______
Beginning Salary ______Ending Salary ______
Major Accomplishments ______
______
______
Previous employer ______Position ______
Address ______
Supervisor’s Name ______Supervisor’s Phone ______
Date Employed ______Date Left ______
Beginning Salary ______Ending Salary ______
Major Accomplishments ______
______
______
Personal References
Please list below five references (professional, educational, or personal).
NameCompany/TitlePhone Number(s)Years Known
1.
2.
3.
4.
5.
Reference Check: Initial and Date (For Office Use Only)
More About You…
*Please tell us about your spiritual walk with the Lord…
Please explain why you want to work at Homes of Hope for Children…
*Please tell us about your family…
Please tell us about your extra-curricular or community activities, hobbies and interests, special skills, or talents. (Use the back of this page.)
Physical Data
*Please describe your physical and mental health in a few brief sentences. (Have you had any major illnesses, physical or mental? Major surgeries? How is your physical stamina?)
Additional Information
Additional information about yourself which will aid in evaluating your interest and qualifications for employment at Homes of Hope for Children:
Houseparent applicants:Please send us a 4x6 photo of your family.
The answers I have given above are true, accurate, and complete. I understand and agree that any false statements contained herein will be sufficient cause to remove my name from consideration for employment. I further understand and agree that if employed, any false statements given above will be sufficient cause for dismissal without any obligation or liability to me other than payment, at the agreed upon rate, for services actually rendered. In addition, I hereby give permission for information to be secured and shared for the purpose of employment consideration.
Date ______Signature ______
“Trust in the Lord with all your heart and lean not unto your own understanding;
In all your ways acknowledge Him, and He will direct your path.”
Proverbs 3:5-6