Employment Application

Position(s) Applying For*
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
If you are not a U.S. Citizen, do you have a VISA to work in the U.S.?*
- Yes
- No
- N/A
Has bond or security clearance ever been denied to you?*
- Yes
- No
Education
Copies of degrees, diplomas, and/or certificates will be required. (Include High School and above)
School*
Name and Address Dates Attended Degree, Diploma or Certificate awarded
Please list any childcare training courses you have completed:*
Employment History
Employment history is required for the past 10 years. If unemployed during any time period, please list how you spend the time, i.e. student, housewife, unemployed, etc)
Employer*
Name and Address Dates Employed Position(s) Held Reason for Leaving Duties/Responsibilities
Do you have a valid drivers license?*
- Yes
- No
Have you had CPR Training in the past two years?*
- Yes
- No
Have you had First Aid Training in the past three years?*
- Yes
- No
Are you willing to participate in annual childcare training?*
- Yes
- No
Are you able to work any shift between 6:30am and 6:30pm*
- Yes
- No
Have you ever been convicted of any offense other than minor traffic offenses?*
- Yes
- No
Have you ever been shown by credible evidence, e.g., a court order or jury, a department’s investigation or other reliable evidence to have abused, neglected or deprived a child or adult or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct?*
- Yes
- No
Under the American with Disabilities Act of 1991, West Haven is required to reasonably accommodate individuals with a disability. The reasonable accommodation requirement applies to the application process, any pre-employment testing, interviews and actual employment, but only if the director or assistant director is made aware that an accommodation is required. If you are disabled and require accommodation, you may request it at any time during the interview process. You are obligated to inform us of your needs if it will impact your ability to perform the job for which you are applying. Having read the job description for the position for which you are applying, are you in all respects able to adequately perform the duties as described?*
- Yes
- No
If no, please explain.
*
I certify that all information on this application is correct. I have not given any false statement concerning my qualification requirements.
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Phone
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Name and Address	Dates Attended	Degree, Diploma or Certificate awarded

Name and Address	Dates Employed	Position(s) Held	Reason for Leaving	Duties/Responsibilities

Employment Application

Education

Employment History