Androscoggin Head Start and Child Care 269 Bates Street Lewiston, Maine 04240 (207) 795-4040 www.AndroKids.com DATE OF APPLICATION: _____________ POSITION APPLYING FOR: _____________________________________ ================================================================================================= * * * * * * * * * * * * * * * * * * PLEASE PRINT CLEARLY * * * * * * * * * * * * * * * * * * * * NAME: ____________________________________________ SOCIAL SECURITY NUMBER: _____________________ ADDRESS: ________________________________________________________________________________________ Street City State Zip Code Home Phone #: (_____)________________________ Daytime phone #: (_____)_____________________ E-Mail Address: ________________________________________________________________ ================================================================================================= Present/Last Employer: _____________________________________________________________________ Address: ___________________________________________________________________________________ Telephone #: (_____)________________________ Dates Employed: From: _______________ To: _______________ Job Title: _________________________________________________________________________________ Supervisor:__________________________________________________________________________________ Work Performed: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Reason For Leaving: ________________________________________________________________________ ================================================================================================= Present/Last Employer: _____________________________________________________________________ Address: ___________________________________________________________________________________ Telephone #: (_____)________________________ Dates Employed: From: _______________ To: _______________ Job Title: _________________________________________________________________________________ Supervisor:__________________________________________________________________________________ Work Performed: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Reason For Leaving: ________________________________________________________________________ ================================================================================================= Present/Last Employer: _____________________________________________________________________ Address: ___________________________________________________________________________________ Telephone #: (_____)________________________ Dates Employed: From: _______________ To: _______________ Job Title: _________________________________________________________________________________ Supervisor:__________________________________________________________________________________ Work Performed: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Reason For Leaving: ________________________________________________________________________ ================================================================================================= Present/Last Employer: _____________________________________________________________________ Address: ___________________________________________________________________________________ Telephone #: (_____)________________________ Dates Employed: From: _______________ To: _______________ Job Title: _________________________________________________________________________________ Supervisor:__________________________________________________________________________________ Work Performed: ____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Reason For Leaving: ________________________________________________________________________ ================================================================================================= May we contact your present employer before making an offer of employment? YES NO REFERENCES: Below list four people who know you well. If possible, list two former employers or supervisors. NAME ADDRESS RELATIONSHIP TELEPHONE _________________________ _________________________ ____________________ _________________ _________________________ _________________________ ____________________ _________________ _________________________ _________________________ ____________________ _________________ _________________________ _________________________ ____________________ _________________ ===================================================================================================== EDUCATION: High School College/University Graduate/Professional School Name _______________________ _______________________ _______________________ Location _______________________ _______________________ _______________________ Years Completed _______________________ _______________________ _______________________ Diploma/Degree _______________________ _______________________ _______________________ Course of Study _______________________ _______________________ _______________________ specialized training, apprenticeship, _______________________ _______________________ _______________________ skills, and extra-curricular _______________________ _______________________ _______________________ activities State any additional _______________________ _______________________ _______________________ information you feel may be helpful to us _______________________ _______________________ _______________________ in considering your application. _______________________ _______________________ _______________________ ===================================================================================================== OFFICE SKILLS: TYPE: Yes _______ No ________ WPM ________ SWITCHBOARD: Yes ________ No ________ STENO: Yes _______ No ________ WPM ________ COMPUTER: Yes ________ No ________ ===================================================================================================== Do you own a car? Yes ________ No ________ License Number: ________________________ State of issue: _____ Exp. Date: ________________ Type of License: _______________________________ Auto Insurance Company: ________________________ Policy Number: ____________________________ ===================================================================================================== How did you learn of this job opening? ________________________________________________________ Do you have any physical condition or handicap which may limit your ability to perform the job applied for? If yes, what can be done to accommodate your limitation? ________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Why should we hire you for this position? Explain: ____________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Have you ever been accused of sexual molestation? Yes______ No_______ (accusation will not necessary disqualify applicant from employment.) Explain:_______________________________________________________________________________________ _______________________________________________________________________________________________ Have you been convicted of a felony within the last 7 years? Yes______ No_______ (conviction will not necessarily disqualify applicant from employment) If yes, please explain: _______________________________________________________________________ _______________________________________________________________________________________________ Has any criminal action relating to children ever been taken against you? Yes______ No_______ SIGNATURE: ______________________________________________________________ Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (proof of citizenship or immigration status may be required upon employment) Yes______ No_______ On what date would you be available for work? ___________________ Are you available to work: FULL-TIME _____ PART-TIME _____ TEMPORARY _____ ===================================================================================================== I understand that falsification of information in the application or interview will be viewed as grounds for refusal or termination of employment. Signature ____________________________________________________________ Date ___________________ WE ARE AN EQUAL OPPORTUNITY EMPLOYER NON-DISCRIMINATION NOTICE In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. £200d et seq.), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. £794) and the Age Discrimination Act of 1975, as amended (42 U.S.C. £6101 et seq.), Androscoggin Head Start and Child Care does not discriminate on the basis of race, color, national origin, handicap or age in admission or a ccess to or treatment or employment in its programs or activities. Mrs. Estelle Rubinstein, Executive Director, has been designated to coordinate efforts to comply with the U.S. Department of Health and Human Services regulations (45 C.F.R. Parts 80, 84 and 91) implementing these federal laws. “We are proud to be a Smoke-Free Agency.” 8/03