(This type of application should be completed by all who seek any position that will involve the supervision and/or custody of children or youth. You should tailor the application to the specific circumstances in your congregation. However, the employment application should include sections for personal identification, job qualifications, experience and background for the past 5-10 years, references, a criminal history, and a waiver/consent to a periodic criminal records check or fingerprinting.)
APPLICANT INFORMATION
Name (Last) (First) (Middle) Date | |
Address City State ZIP Code | |
Telephone Alternate Telephone Best Contact Time E-Mail Address | |
Social Security Number Driver's License No./Issuing State Date of Birth | |
Position Apply For Type of Work Desired Full-Time Part-Time Temporary/Contract | |
When Are You Available to Begin Work? Will You Work Overtime? Yes No | |
If hired, can you provide evidence that you are authorized and of legal age to work in the United States? Yes No | |
In Case of Emergency Notify Telephone | Name of Nearest Relative Telephone |
EDUCATION
TYPE | SCHOOL NAME/LOCATION | COURSE OF STUDY | NO. YEARS ATTENDED | DEGREE/DIPLOMA |
HIGH SCHOOL | ||||
BUSINESS/TECHNICAL | ||||
COLLEGE | ||||
GRADUATE | ||||
OTHER |
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Professional Organizations: |
First-Aid Training? Date Completed Yes No |
CPR Training? Date Completed Yes No |
EMPLOYERS
(List all jobs and contracts held by you during the past five continuous years)
CURRENT EMPLOYER
Company Name Telephone |
Address City State ZIP Code |
Position Held From To Starting/Ending Salary |
Reason for Leaving Supervisor |
PREVIOUS EMPLOYER
Company Name Telephone |
Address City State ZIP Code |
Position Held From To Starting/Ending Salary |
Reason for Leaving Supervisor |
PREVIOUS EMPLOYER
Company Name Telephone |
Address City State ZIP Code |
Position Held From To Starting/Ending Salary |
Reason for Leaving Supervisor |
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PREVIOUS EMPLOYER
Company Name Telephone |
Address City State ZIP Code |
Position Held From To Starting/Ending Salary |
Reason for Leaving Supervisor |
PREVIOUS EMPLOYER
Company Name Telephone |
Address City State ZIP Code |
Position Held From To Starting/Ending Salary |
Reason for Leaving Supervisor |
MILITARY STATUS
Have You Served in the U.S. Armed Services? Branch Start Date End Date Yes No |
Rank/Rate at Discharge Type of Service Type of Discharge |
Special Training/Experience Received in the U.S. Armed Services Draft Status Reserve Status |
CRIMINAL HISTORY
Have you ever been convicted of a criminal offense? Check One: Yes No |
Do you currently have any criminal actions pending in which you are the Defendant? (Not Applicable to California Applicants) Check One: Yes No |
Are you currently on probation or parole? Check One: Yes No |
If you answered "Yes" to any of the above questions, please explain the nature of the offense and provide the date of the offense and the county and state in which it occurred. |
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PERSONAL REFERENCES:
Name Address Phone Occupation Relationship |
Name Address Phone Occupation Relationship |
Name Address Phone Occupation Relationship |
APPLICANT STATEMENT
(Read and Sign Below)
I certify that this employment application was completed by me and that all of the information on this application is true and correct to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts called for herein will result in my disqualification from further consideration or dismissal from employment if I am hired. I have reviewed the Authorization for Criminal Records Verification and Fingerprint Information and acknowledge that I understand the terms set forth therein. I understand that this employment application is not valid without my signature.
Print Name |
Signature Date |
CHURCH MUTUAL INSURANCE COMPANY AND HERMES SARGENT BATES WISH TO POINT OUT THAT NO WARRANTY ATTACHES TO THESE DOCUMENTS, AND IN FACT , THESE DOCUMENTS MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR ENTITY. THESE DOCUMENTS ARE NOT A SUBSTITUTE FOR GOOD PRACTICE , PROPER SUPERVISION, AND DILIGENT OVERSIGHT AND CONTROL. THERE IS NO GUARANTEE THAT THESE DOCUMENTS WILL PROTECT ANY FACILITY THAT CHOOSES TO USE THEM. BEFORE USING THESE DOCUMENTS OR ANY SIMILAR DOCUMENTS, YOU SHOULD CONSULT WITH YOUR OWN ATTORNEY TO MAKE CERTAIN THAT THE DOCUMENT YOU EVENTUALLY USE IS CORRECT AND CURRENT UNDER THE LAW OF YOUR PARTICULAR JURISDICTION AND THAT THE DOCUMENT MEETS YOUR NEEDS FOR YOUR PARTICULAR SITUATION.
FM:S868 (8-2008) HSB -4-