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                                              Employment Application

Last Name__________________________ First Name____________________ Middle Name_______________

Social Security #___________________ Occupation________________________________________________

Spouse’s Name______________________________________________________________________________

Social Security # ___________________Occupation:________________________________________________

Current Physical Address______________________________________________________________________

Current Postal Address________________________________________________________________________

Home phone #____________________________________Cell phone #________________________________

Work phone #____________________________________Spouse’s Work # ____________________________

Names and Birthdates of Children ______________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

List all persons living at home _________________________________________________________________

_________________________________________________________________________________________

Name, Address, Phone Number of Minister of Church now attending:_________________________________

_________________________________________________________________________________________

Do you have any serious physical problems? If so, please explain.____________________________________

_________________________________________________________________________________________

Does your spouse have any serious physical problems? If so, please explain. ___________________________

_________________________________________________________________________________________

When would you be available for employment? __________________________________________________

 

GENERAL DATA: Do you use tobacco in any form?______Do you drink alcoholic beverages?______

Do you curse or use abusive language? ______Have you ever been convicted of a felony? _______

Have you ever been convicted on a moral charge___________, a physical violence charge__________,

child abuse or neglect charge? _____________ Are you a member of the Church of Christ?_________

Have you ever been married to anyone other than your present spouse?_____________

SPOUSE'S GENERAL DATA: Do you use tobacco in any form?_____Do you drink alcoholic

beverages?_____Do you curse or use abusive language? __________Have you ever been convicted of

a felony? _________ Have you ever been convicted on a moral charge______________, a physical

violence charge__________,child abuse or neglect charge? _______________ Are you a member

of the Church of Christ?_________ Have you ever been married to anyone other than your

present spouse?_________

POSITION QUALIFIED FOR AND DESIRED:

 Houseparent _________________ Office Work ______________________ Kitchen _______________

PREVIOUS EMPLOYMENT: (List most recent first)

 Name                                                             Address                                                      Phone #                                       __________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

SPOUSE'S PREVIOUS EMPLOYMENT: (List most recent first)

 Name                                                             Address                                                      Phone #                                       __________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Have you or your spouse ever worked at a children’s home or facility? ___yes  ___no If so,

name and location of home_____________________________________________________________

Have you or your spouse ever been involved in a child welfare investigation in this or any other 

state?__yes __no Have you or your spouse ever been convicted of or entered a plea of guilty or

 nolo contendere (no contest) to any criminal activity involving violence against a person; child

abuse or neglect; possession, sale or distribution of illegal drugs; sexual misconduct; gross

irresponsibility or disregard for the safety of others? ___yes ___no  If yes, provide additional

information. ________________________________________________________________

_______________________________________________________________________________________________________

SPECIAL SKILLS OR QUALIFICATIONS: _______________________________________________________

 _______________________________________________________________________________________________________

                                        APPLICANT’S STATEMENT TO THE TIPTON HOME

I verify all answers and responses on this application are true and complete.  I authorize The Tipton

Home to investigate any information on this application.  I understand The Tipton Home will check

for any criminal history.  I understand any false or misleading information given by me may result

in my discharge from employment.  I also understand that, if I am hired, I am required to abide by

all rules and regulations of The Tipton Home, the State of Oklahoma and any other agency with

jurisdiction over The Tipton Home. I understand to be employed, I must provide proof of citizenship. 

I agree that any employment relationship with The Tipton Home is an “at will” nature, which means

I may resign at any time and The Tipton Home may discharge me at any time with or without cause. 

It is likewise agreed this “at will” employment relationship may not be changed except by the Executive

Director’s written authorization.

 ________________________________________                    _____________________

         Signature of Applicant                                                           Date of Signature

_________________________________________                    _____________________

            Signature of Spouse                                                              Date of Signature

My signature being affixed gives The Tipton Home permission to do a criminal check through the

Oklahoma Bureau of Investigation and any and all states where I may have resided or are presently

 residing.

____________________________   _________    ____     ____   ____________

Signature of Applicant                                        Date of Birth         Sex         Race       Date of Signature

Alias Names (includes maiden name, all married names, and any other names used)

________________________________________________________________________________________________________                                                                            

My signature being affixed gives The Tipton Home permission to do a criminal check through the

Oklahoma Bureau of Investigation and any and all states where I may have resided or are presently

residing.

________________________________     __________      ____       ____        ____________

       Signature of Spouse of Applicant                            Date of Birth             Sex            Race           Date of Signature

Alias Names (includes maiden name, all married names, and any other names used)

___________________________________________________________________________________________________________

Form for Applicant

OAC 340:110                                                                                                  Department of Human Services

                              APPENDIX E.  CHILD CARE STAFF INFORMATION

 Applicant’s/Employee’s Name ______________________________________ S.S. # _______________

Address ________________________________________________________Phone ______________

 EDUCATION  (Circle highest year completed) Elementary                 High School                     College

                                                                         1   2  3  4  5  6  7  8                9  10  11  12                 1  2  3  4  5  6

 High School name, location and date graduated________________________________________________________

____________________________________________________________________________________________

GED:  ________________________________________________________________ CDA: ________________

                       Test Location                                Date Received                                                                                 Date Received

College name, location and date graduated___________________________________________________________

___________________________________________________________________________________________      Degree                                                                             Major                                                               Minor

Are you at least 16 years of age? ____Yes___No;18 years of age? ___Yes___No;

21 years of age? ___Yes ___No

 Experience in group care of children________________________________________________________________

____________________________________________________________________________________________

PERSONAL REFERENCES Initial Application only (list three persons, not related to you, that are

familiar with your child care practices)

                      Name                                                    Postal Address                                                                      Phone #

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Have you ever been involved in a child welfare investigation in this or any other state? ___Yes ___No Have

you ever been convicted of or entered a plea of guilty or nolo contender (no contest) to any criminal

activity involving violence against a person; child abuse or neglect; possession, sale or distribution of

illegal drugs; sexual misconduct; gross irresponsibility or disregard for the safety of others?___Yes ___No 

If yes, provide additional information on back of form.  I hereby certify that this information is true and

complete to the best of my knowledge.  I also authorize a complete background check, including

verification of education and employment, reference check and criminal background check.

Signature _________________________________________Date ________________

Form for spouse of applicant:

OAC 340:110                                                                                                Department of Human Services

                              APPENDIX E.  CHILD CARE STAFF INFORMATION

 Applicant’s/Employee’s Name _______________________________________S.S. # _________________

 Address ________________________________________________________Phone ______________

 EDUCATION  (Circle highest year completed) Elementary              High School                     College

                                                                              1   2  3  4  5  6  7  8        9  10  11  12                 1  2  3  4  5  6

 High School name, location and date graduated________________________________________________

_____________________________________________________________________________________

GED:  ____________________________________________________________ CDA: ________________

                        Test Location                               Date Received                                                                       Date Received

College name, location and date graduated_____________________________________________________

_____________________________________________________________________________________   Degree                                                                           Major                                                                          Minor

Are you at least 16 years of age? ____Yes___No;18 years of age? ___Yes___No;

21 years of age? ___Yes ___No

 Experience in group care of children ____________________________________________________________

PERSONAL REFERENCES Initial Application only (list three persons, not related to you, that are

familiar with your child care practices)

                      Name                                              Postal Address                                                          Phone #

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever been involved in a child welfare investigation in this or any other state? ___Yes ___No

Have you ever been convicted of or entered a plea of guilty or nolo contender (no contest) to any

criminal activity involving violence against a person; child abuse or neglect; possession, sale or

distribution of illegal drugs; sexual misconduct; gross irresponsibility or disregard for the safety

 of others?____Yes ____No  If yes, provide additional information on back of form. I hereby certify

that this information is true and complete to the best of my knowledge. I also authorize a complete

background check, including verification of education and employment, reference check and criminal

background check.

Signature _________________________________________Date ________________

 

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