Application for Employment

Date: ______

Position applying for:

Dateavailabletobegin:

How did you hear about this job opening?

Are you willing and able to work all shifts applicable to the position applied for, as stated in the attached job description? Yes No

How did you hear about The Covering House?

Have you ever been employed by The Covering House?Yes No

If yes, give date and title:

Are you willing to submit to a background check as a condition of employment? Yes No

Are you willing to submit to drug testing as a condition of employment? Yes No

Are you willing to sign a confidentiality agreement as a condition of employment? Yes No

PERSONAL/BACKGROUND INFORMATION (please print):

Last Name: First Name:

Address: Apt#:

City: State: Zip:

Primary contact number: Alternate contact number:

E-Mail:

Are you at least 21 years old? Yes No

Please list all states in which you have lived at any time during the last five (5) years:

Are there any other names by which you have been known? Yes No

If yes, please list all other names by which you have been known:

Have you ever been listed on the Employment Disqualification List (EDL) by the Missouri Department of Social Services or Department of Mental Health, or the equivalent in any other state? Yes No

Doyouhaveavaliddriver’slicense? Yes No If yes, please provide:

License#:

Issuing state:

ExpirationDate:

Have you ever been charged with, been found guilty of, pled guilty to, or pled no contest to afelony or misdemeanor? Yes No Ifyes,pleaseprovide an explanation, including date, city, state, charge and disposition:

In the last five (5) years,have you been found guilty of, pled guilty to, or pled no contest to any charge or offense relating to driving under the influence of alcohol or any other intoxicating substance?

Yes No_____

Ifyes,pleaseprovide the date, city, state, and an explanation, including charge and disposition:

EMPLOYMENT/EDUCATION/QUALIFICATIONS:

List all diplomas, degrees, certifications, licenses, or other credentials that you hold or skills that you possess relevant to the position applied for:

In the past ten years, have you had any disciplinary action taken against you related to any professional certificate of registration, authority, permit, or license, or had such professional certificate of registration, authority, permit, or license suspended or restricted in any manner? Yes No If yes, please provide the date, city, state, and an explanation:

Please list all employers for the past five years beginning with your current/most recent job held. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number / Name of last
Supervisor: / Employment dates:
From
To / Pay or salary:
Start
Final
Your last job title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
Name of employer
Address
City, State, Zip Code
Phone number / Name of last
Supervisor: / Employment
Dates:
From
To / Pay or salary:
Start
Final
Your last job title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:
Name of employer
Address
City, State, Zip Code
Phone number / Name of last
Supervisor: / Employment dates:
From
To / Pay or salary:
Start
Final
Your last job title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company:

Have you, at any time, worked in a child care setting, either paid or as a volunteer? Yes _____ No_____

If yes, please list every child care setting in which you have worked. Attach additional sheets if necessary.

Name of employer
Address
City, State, Zip Code
Phone number / Your last job title: / Name of last
Supervisor: / Employment dates:
From
To
Reason for leaving (be specific):
List the jobs you held, duties performed:
Name of employer
Address
City, State, Zip Code
Phone number / Your last job title: / Name of last
Supervisor: / Employment dates:
From
To
Reason for leaving (be specific):
List the jobs you held, duties performed:

List professional, trade, business, or civic organizations in which you are involved. (You may exclude memberships that would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status.)

Do you feel you can perform the essential functions of the job for which you are applying, as described in the attached job description? Yes No

If no, is there any accommodation that you believe can reasonably be made which would permit you to perform the essential functions of the job for which you are applying? If yes, explain.

CHARACTER REFERENCES

Listthree(3)people who are unrelated to you. *Please PRINT clearly.

Name:Relationship

DaytimePhone:Email:

Name:Relationship:

DaytimePhone:Email:

Name:Relationship:

DaytimePhone:Email:

I,, hereby affirm that all of the answersprovidedonmy application are true to the best of my ability. Iunderstandthatany misrepresentationor omission isgrounds for dismissal.

IherebyauthorizeThe Covering House toconduct a child abuse/neglect and criminal background screening, and to contact each of my employers within the last five (5) years and each of the character references listed above.

Signature:Date: