Application for Employment
RequiredRequired Question(s)
1.
Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.

Recruitment Source:

Newspaper/Internet Ad
Referred by SSDC employee or Board Member
Smart Start of Davie County
Self-Knowledge
Other  
Required 3.

Applicant Certification Statement:

By signing my name below, I (1) certify that all statements made by me on this application are true and complete to the best of my knowledge and that I understand that misrepresentations or omissions may be cause for rejection or may be cause for subsequent dismissal if I am hired, and (2) understand that nothing contained in this application or in the interview process is intended to create an employment contract between Smart Start of Davie County, Inc. and me, and (3) authorize the employer to contact and obtain information provided in this application.  I hereby waive all rights and claims I may have regarding the employer for seeking, obtaining and using truthful information in the employment process and all other persons corporations or organizations for furnishing such information about me.  If this application results in my employment, I understand I have the right to terminate my employment any time and for any reason and Smart Start retains a similar right.  I further understand that no representative of Smart Start has any authority to enter into agreement with me for any specified period of time or to guarantee some other personnel benefit. I further understand this entire statement applies to the period prior to or after I may be employed.  I understand this application will remain current for only 30 days and after that time, it will be necessary for me to reapply and fill out a new application.

I hereby acknowledge that I have have read and understand each of the above statements.

 

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4.

What is your desired pay/salary? 

 

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5.

Check type of employment desired.

Full-time
Part-time
6.

What date are you available for employment?

 

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7.
Have you ever filed an application with us before? If yes, give dates.
 

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8.

Have you ever worked for Smart Start before?  If yes, give dates.

 

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9.
Can you travel if required by this position?  Do you have a valid driver's license.
Yes
No
10.
Are you at least 18 years of age?  Are you legally eligible to work in the United States?
Yes
No
11.
Have you ever been dismissed or forced to resign from a prior job? If yes, describe in detail.
Yes
No
  • Comment:

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12.

Have you ever been convicted of a crime (other than a minor traffic violation)?  If yes, list all offense(s) and date(s) of conviction/plea and county/city/state of conviction.*


*Conviction of a crime will not necessarily prevent acceptance for employment.

Yes
No
  • Comment:

  • 500 characters left.
13.

Are you currently employed?  

Yes
No
14.
If yes, may we contact your current employer?
Yes
No
15.

List three references that are not relatives with contact information including company name- (one per block)

 

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16.

Reference 2 of 3.

 

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17.

Reference 3 of 3.

 

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18.

Employment History

Employer:

Address:

Number:

Job Title:

Supervisor:

Reason for Leaving:

Dates Employed:

Hourly Rate/Salary:

Work Performed:

 

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19.

Employment History

Employer:

Address:

Number:

Job Title:

Supervisor:

Reason for Leaving:

Dates Employed:

Hourly Rate/Salary:

Work Performed:

 

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20.

Employment History

Employer:

Address:

Number:

Job Title:

Supervisor:

Reason for Leaving:

Dates Employed:

Hourly Rate/Salary:

Work Performed:

 

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21.

Education:  Please complete where you attended and years completed.

High School:

Undergraduate:

Graduate:

Other:

 

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22.

Are you currently enrolled in school?  If yes, name of school and course of study.

Yes
No
  • Comment:

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23.

List fields of work for which you are licensed, registered or certified, giving date(s), source(s), of issuance, and number(s):

 

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24.

List professional, trade, business or civic activities or office(s) held.  You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

 

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25.

Thank you for your interest in Smart Start of Davie County as a potential employer!  We consider applicants for all the position without regard to race, color, religion, creed, gender, national origin, age, disability, veteran status, or any other legal protected status.  We assure you that your opportunity for employment with this organization depends solely on your qualifications.

 

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