Job Application – General Last Name (required) First Name (required) Middle Initial (required) Home Phone Cell Phone Email (required) Address Street City State Zip Position(s) Applied For Date Available For Work Educational Background: High School Name High School Location Last Year of High School Completed 1234 High School Degree Did You Graduate High School?YesNo College or University Name College or University Location Last Year of University Completed 1234 University Degree Did You Graduate from College/University?YesNo Graduate School Name Graduate School Location Last Year of Graduate School Completed 1234 Graduate Degree Did You Graduate?YesNo Special Training Do you plan to pursue further education? YesNo If so, in what field of study? If you did not graduate, why did you leave high school or college? Describe the skills and abilities you possess that qualify you to represent the mission of our agency. You may also want to include civic and community activities and professional societies in which you participate. Have you ever had a child enrolled in any Head Start or Early Head Start program? YesNo How did you learn of this opening? Employment History: Please outline your last 10 years of employment below. Start with your most recent employer. Employer Name, Address and Zip Code: Employer Phone Number: How Long Employed Here? Job Title: Supervisor Name: Supervisor Number: Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer Name, Address and Zip Code: Employer Phone Number: How Long Employed Here? Job Title: Supervisor Name: Supervisor Number: Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer Name, Address and Zip Code: Employer Phone Number: How Long Employed Here? Job Title: Supervisor Name: Supervisor Number: Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer Name, Address and Zip Code: Employer Phone Number: How Long Employed Here? Job Title: Supervisor Name: Supervisor Number: Reason for Leaving: Summarize the type of work performed and job responsibilities: Employer Name, Address and Zip Code: Employer Phone Number: How Long Employed Here? Job Title: Supervisor Name: Supervisor Number: Reason for Leaving: Summarize the type of work performed and job responsibilities: Personal References: List the names and telephone numbers of four people who are not related to you, but have known you for at least three years. Name Complete Address Phone How are they associated with you? Name Complete Address Phone How are they associated with you? Name Complete Address Phone How are they associated with you? Name Complete Address Phone How are they associated with you? I hereby certify, to the best of my knowledge, that the information outlined on this Application for Employment is true, accurate and complete. Any misrepresentation or willful omission of facts shall be sufficient cause for disqualification of this application or termination of employment. Furthermore, it is understood that this application and records become the property of the agency which reserves the right to accept or reject it. I further agree to observe all rules, regulations and policies of the agency. PACT has my permission to contact and solicit information from the listed former employers and personal references. I hereby also authorize my former employers and personal references to furnish their record of service, my reason for leaving their employ, together with all information they have concerning me whether on record or not. I also release any individual, partnership or corporation which formerly employed me, its officers, agents and employers from any liability for any damage whatsoever for issuing such information. Parent and Child Together (PACT) for West Central Illinois is an Equal Opportunity Employer. Agency grievance procedures are available upon request to any applicant who feels they have been discriminated against on the basis of race, religion, sex, national origin or handicapping condition.
