Job Application – General — PACT for West Central Illinois

Personal Information

Last Name *

First Name *

Middle Initial *

Home Phone

Cell Phone

Email *

Street Address

City

State

Zip

Position(s) Applied For

Date Available for Work

Educational Background

High School

School Name

Location

Last Year Completed

Degree

Graduated?

Yes No

College / University

School Name

Location

Last Year Completed

Degree

Graduated?

Yes No

Graduate School

School Name

Location

Last Year Completed

Degree

Graduated?

Yes No

Special Training

Do you plan to pursue further education?

Yes No

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 include civic and community activities and professional societies.

Have you ever had a child enrolled in any Head Start or Early Head Start program?

Yes No

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 1

Employer Name, Address and Zip Code

Employer Phone Number

How Long Employed Here?

Job Title

Supervisor Name

Supervisor Phone Number

Reason for Leaving

Summarize the type of work performed and job responsibilities

Employer 2

Employer Name, Address and Zip Code

Employer Phone Number

How Long Employed Here?

Job Title

Supervisor Name

Supervisor Phone Number

Reason for Leaving

Summarize the type of work performed and job responsibilities

Employer 3

Employer Name, Address and Zip Code

Employer Phone Number

How Long Employed Here?

Job Title

Supervisor Name

Supervisor Phone Number

Reason for Leaving

Summarize the type of work performed and job responsibilities

Employer 4

Employer Name, Address and Zip Code

Employer Phone Number

How Long Employed Here?

Job Title

Supervisor Name

Supervisor Phone Number

Reason for Leaving

Summarize the type of work performed and job responsibilities

Employer 5

Employer Name, Address and Zip Code

Employer Phone Number

How Long Employed Here?

Job Title

Supervisor Name

Supervisor Phone 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.

Reference 1

Name

Phone

Complete Address

How are they associated with you?

Reference 2

Name

Phone

Complete Address

How are they associated with you?

Reference 3

Name

Phone

Complete Address

How are they associated with you?

Reference 4

Name

Phone

Complete Address

How are they associated with you?

Certification

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.

I certify that all information provided is true and accurate, and I agree to the terms above. *