ChildCare Careers EMPLOYMENT APPLICATION (ChildCare Careers is an Equal Oppertunty Employer Social Security Number: -Cr Hl Date: Full Name: Drivers’ License/ID Number: State: Expiration Date: ‘Are you legally authorized to accept employment in the US? 0) Yes. O No (erifcation and completion of Form 1-9 required). Have you ever been convicted ofa felony or misdemeanor criminal offense? 1 Yes C1No Have you in the past 90 days submitted fingerprints to the Department of Children and Families (DCF) or been fingerprinted fora child care facility? C1 Yes C1No Have you ever used another name that we would need in order to verify your past employment, education, and/or fingerprint clearance? No (I Yes: Have you ever held a child care license with the Department of Children and Families or been registered to provide child care in your home? Yes CNo While employed in a child care program, have you ever been the subject of disc been the party responsible for a child care facility receiving an administrative fine or other disciplinary action? (No O Yes Ifyes, please explain: If you have worked in child care in Florida in the past, please list the last date of employment and the name of the schoo!?, ‘Are you able to perform the essential functions of the job (including bending, lifting of up to 50 pounds, standing for long periods of time, walking rapidly, kneeling, crouching, sitting on low chait/foor, hearing, seeing) for which you are applying, ether with or without reasonable ‘accommodation? OyYes O No IENO, describe the functions that cannot be performed: ‘ote: CallCare Careers complies wih the ADA and consider reasonable accommodation mearires that may be necessary for eligible applicants lo perform essential frctions. © chidcare Carvers, LLC Rovisod: 4142016Employment Desired: Position: Hourly Wage: ‘Date available to stan work: ‘Are you currently employed? 1 Yes No Have you ever applied for employment or worked at any branch of ChildCare Careers inthe past? CONo Ces Ifyes, what branche Date Do you have any relatives currently employed by ChiliCare Careers? 1 Yes (1 No ‘Réncations, : No. of Did: Diploma Type of School! iced Gradiae? or High Soot ‘Cammanly Coleg College/University School ‘Volunteer or Unpaid Experience In Child Care: — a List below all present and past employment stating with your most recent ‘employer (last 10 years is suffciem). Account for all periods of unemployment. “You must ‘complete this section even if you are ataching a resume, @casecare corer, UC : ‘Sate cent‘Reasoa for Leaving: Resigned Discharged Lag OF Gi otter EO Pe | Yelephoaetfan “hay we conned? | @canscare carers 11 anne e1an18