 |
 |
 |
|
|
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 ________________
|
|
