*Preferred Location:
*Date of Application:
All applicants will be considered for employment without regard to race, religion, color, sex, national origin, age, martial or veteran status, medical condition or handicap, or any other status protected by the law. Minnieland is an Equal Opportunity Employer. |
| POSITION APPLIED FOR
|
Full Time
Part Time
|
| *Expected Salary per hour: |
*Expected Salary per year: |
*Email Address |
|
|
|
| PERSONAL DATA |
| *Name (last, first, middle) |
|
|
|
|
|
| *Address |
*City |
*State |
|
|
|
| *Zip Code |
*Home Phone |
Business Phone |
|
|
|
| Are you at least 18 years of age? |
*Date you are available to start work? |
| Yes
No
|
|
| If requesting part time, list days and hours available |
|
|
| Have you worked for us before? |
In what position? |
When? |
| Yes
No
|
|
|
| Where? |
|
|
|
|
|
| EDUCATION |
| Check the highest grade completed 1
2
3
4
5
6
7
8
9
10
11
12
|
Name and location of high school
Year Graduated
|
If you did not complete high school, do you have a high school equivalency diploma?
Yes
No
Date received
|
| Check number of years of education past high school 1
2
3
4
5
6
7
|
| Name and location of school/College/University
|
| Dated attended |
Hours |
Degree received |
|
|
|
| Specialty |
Minor |
|
|
|
|
| If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date.
|
| First Aid Certification |
Yes
No
|
Expiration Date
|
| CPR Certification |
Yes
No
|
Expiration Date
|
EXPERIENCE
Starting with your most recent job, describe all paid and military positions. Use additional pages if necessary. |
| 1.Job Title |
Salary |
Employer |
|
|
|
| Address |
Phone |
Type of Business |
|
|
|
| Immediate supervisor |
Dates of employment (From)
(To)
|
|
Full Time
Part Time
Hours per week
|
Job Duties
|
| May we contact your employer for a reference |
Yes
No
|
| 2.Job Title |
Salary |
Employer |
|
|
|
| Address |
Phone |
Type of Business |
|
|
|
| Immediate supervisor |
Dates of employment (From)
(To)
|
|
Full Time
Part Time
Hours per week
|
Job Duties
|
| May we contact your employer for a reference |
Yes
No
|
| 3.Job Title |
Salary |
Employer |
|
|
|
| Address |
Phone |
Type of Business |
|
|
|
| Immediate supervisor |
Dates of employment (From)
(To)
|
|
Full Time
Part Time
Hours per week
|
Job Duties
|
| May we contact your employer for a reference |
Yes
No
|
In narrative form, describe your special skills, talents, volunteer work or training that would help us evaluate your application.
|
REFERENCE
List names, addresses, and relationships to you of three people (not related to you) whom we may contact information about your qualifications |
| 1. Name/Title |
Company |
Work Phone |
|
|
|
| Address |
City |
State |
|
|
|
| Zip |
Relationship to you |
|
|
|
|
| 2. Name/Title |
Company |
Work Phone |
|
|
|
| Address |
City |
State |
|
|
|
| Zip |
Relationship to you |
|
|
|
|
| 3. Name/Title |
Company |
Work Phone |
|
|
|
| Address |
City |
State |
|
|
|
| Zip |
Relationship to you |
|
|
|
|
| MISCELLANEOUS DATA |
| Have you ever been convicted of an offense (excluding minor traffic violations)? Yes
No
|
If you are hired, you will be required to have a criminal records background check. Is this acceptable to you?
Yes
No
|
Is there anything that would interfere with your ability to successfully perform the duties of this position?
Yes
No
If yes, please specify:
|
| List person to be contacted in case of emergency: |
|
| Name |
Address |
Phone |
|
|
|
| SWORN DISCLOSURE STATEMENT |
Have you ever been convicted of or are you the subject of pending charges for any of the following offenses: Murder; malicious wounding by mob; abduction; abduction for immoral purposes; assault and bodily wounding; robbery; car jacking; extortion by threat; any felony stalking violation; sexual assault; arson; burglary; any felony violation relation to possession or distribution of drugs; drive by shootings; use of a machine gun in a crime of violence; aggressive use of a machine gun; use of sawed-off shotgun in a crime of violence; pandering; crimes against nature involving children; incest; taking indecent liberties with children; abuse and neglect of children, including failing to secure medical attention for an injured child; obscenity offenses; possession of child pornography; electronic facilitation of pornography; abuse and neglect of incapacitated adults; employing or permitting a minor to assist in an act constituting an obscenity or related offense; delivery of drugs to prisoners; escape from jail; felonies by prisoners, within the Commonwealth or any equivalent offense outside the Commonwealth? |
|
Yes (Convicted) |
Yes (Pending) |
No |
If yes, specify crime(s):
|
| Have you ever been convicted of or are you the subject of pending charges for any other felony in the five years prior to the application date for licensure, registration, employment, or approval? |
|
Yes (Convicted) |
Yes (Pending) |
No |
If yes, specify crime(s):
|
| Have you ever been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth? Yes
No
|
Text Version of Resume (optional):
|
I hearby affirm that the above information is true and complete to the best of my knowledge. I understand that it may be subject to verification. Should I be employed by Minnieland, any misrepresentation or false statement made on this application may be considered cause for possible
dismissal. Minnieland has my permission to obtain all necessary information from the references I have listed concerning my prior employment.
I release all parties from any possible damages resulting from disclosing such information with or without prior written notice from me.
If hired, I understand this application is considered a contract. In the Commonwealth of Virginia, I am considered an at will employee and may
be terminated by Minnieland Private Day School, Inc. at any time. |
| Applications Signature (This application is valid for 60 days) |
Date: |
|
|
| FOR OFFICE USE ONLY |
| Accepted for employment |
Position |
Starting rate $ per hour |
|
|
|
| Starting date |
Interviewed by |
Date |
|
|
|
| Approved for hire by |
Date |
|
|
|
|
| |
|
|
