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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 ________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ POSITION QUALIFIED FOR AND DESIRED: Houseparent _________________ Office Work ______________________ Kitchen ______________________ Have you or your spouse ever worked at a children’s home or facility? ___yes ___no If so, name and location of home_____________________________________________________________________ Experience in group care of children_______________________________________________________________ __________________________________________________________________________________________ Spouse's Experience in group care 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. ___________________________ _________________________________________________________________________________________ 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?_________ 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 SPOUSE'S 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 PREVIOUS EMPLOYMENT: (List most recent first) Date Name Address Phone # __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ SPOUSE'S PREVIOUS EMPLOYMENT: (List most recent first) Date Name Address Phone # __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ PERSONAL REFERENCES (list three persons, not related to you, that are familiar with your child care practices) Name Postal Address Phone # ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SPOUSE'S PERSONAL REFERENCES (list three persons, not related to you, that are familiar with your child care practices) Name Postal Address Phone # _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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 ornolo 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) ___________________________________________________________________________________________________________ When would you be available for employment? __________________________________________________
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