LATCHKEY CHILD SERVICES, INC.

Employment Application

PERSONAL INFORMATION

Last Name:

First:

Middle:

Social Security #:

Address:

City:

State:

ZIPcode:

Home Telephone:

Cell Telephone:

Referred By:

EMPLOYMENT DESIRED

Position Desired:

Date You Can Start:

Salary Desired:

Are You Employed?:
Yes No

May We Contact Your Present Employer?:
Yes No

Ever Applied To LCSI Before?:
Yes No

EDUCATION

High School:

Years Attended:

Did You Graduate:

Subjects Studies:

College:

Years Attended:

Did You Graduate:

Subjects Studies:

Other:

Years Attended:

Did You Graduate:

Subjects Studies:

GENERAL

Subjects of Special Study or Special Training/Skills:

FORMER EMPLOYERS

EMPLOYER

From: To:

Name: Address: Telephone:

Salary: Position:

Reason For Leaving:

EMPLOYER

From: To:

Name: Address: Telephone:

Salary: Position:

Reason For Leaving:

EMPLOYER

From: To:

Name: Address: Telephone:

Salary: Position:

Reason For Leaving:

REFERENCES - (KNOWN AT LEAST ONE YEAR)

Name, Title, or Position:

Address/Phone:

Business or Personal:

Name, Title, or Position:

Address/Phone:

Business or Personal:

Name, Title, or Position:

Address/Phone:

Business or Personal:

MISCELLANEOUS INFORMATION

Additional information you feel is pertinent - please use this space:

DO YOU HAVE ANY MEDICAL, PHYSICAL, EMOTIONAL CONDITIONS OR PERSONAL CONFLICTS THAT WOULD PREVENT YOU FROM PERFORMING DAILY ROUTINE DUTIES OF SUPERVISING CHILDREN AGES 3 TO 14? DUTIES INCLUDE, BUT ARE NOT LIMITED TO: WALKING, RUNNING, STANDING, SITTING, READING, WRITING, AND LIFTING (NOT TO EXCEED 40 LBS.): Yes No

IF YES, PLEASE DESCRIBE IN DETAIL:

BACKGROUND

HAVE YOU EVER BEEN CONVICTED OF OR ENTERED A PLEA OF GUILTY OR NOLO CONTENDERE (NO CONTEST) TO ANY CRIMINAL ACTIVITY INVOLVING VIOLENCE AGAINST A PERSON; CHILD ABUSE OR NEGLECT; POSSESSION, SALE OR DISTRIBUTION OF ILLEGAL DRUGS; SEXUAL MISCONDUCT; GROSS IRRESPONSIBILITY OR DISREGARD FOR THE SAFETY OF OTHERS? Yes No

AUTHORIZATION

I HEREBY CERTIFY THAT THIS INFORMATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I ALSO AUTHORIZE A COMPLETE BACKGROUND CHECK, INCLUDING VERIFICATION OF EDUCATION AND EMPLOYMENT, REFERENCE CHECK AND CRIMINAL BACKGROUND CHECK. IF HIRED, ANY FALSIFICATION OF INFORMATION HEREIN OR ON THIS APPLICATION FORM CAN RESULT IN IMMEDIATE DISMISSAL.

Date

Signature

“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION. I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE.”

Date

Signature:

Email Address: