CCSA Employment Application Step 1 of 7 14% Title of the position you are applying for? list the title of the position you are interested in applying for.Personal DataName(Required) Last First Middle LIST OTHER NAMES used in past 7 years; including birth names, maiden names, and A.K.A’s. Home Address(Required) Street Address City NCAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address(Required) Home PhoneCell Phone(Required)Other PhoneNumber of years at current address. If less than 7 years list all other cities and states which you lived during the past 7 years.(Required)Previous AddressesAre you 18 years of age or older?(Required) Yes No Birth Month(Required)JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberBirth Day(Required)12345678910111213141516171819202122232425262728293031Other than a minor traffic offense, have you ever been convicted of a crime? This includes allegations of and/ or substantions of sexual or physical abuse and neglect of a child. (A conviction record will not necessarily bar you from employment.)(Required) Yes No IF YES, provide details below, including date and location of offense.Are you legally eligible for employment in this country?(Required) Yes No Proof of Eligibility will be required upon employment.Do you have any relatives presently employed with Child Care Services Association?(Required) Yes No Name of CCSA Employee First Last Relation Job Title Have you ever received services from Child Care Services Association?(Required) Yes No If YES, do you have any oustanding debts with Child Care Services Association? Yes No Have you ever applied with Child Care Services Association previously?(Required) Yes No If YES, when? MM slash DD slash YYYY Starting Date of Employment MM slash DD slash YYYY Ending Date of Employment MM slash DD slash YYYY Position Held PositionPosition Desired(Required) Salary Expected $ per monthPlease include desired dollar amount per month.What date are you available?(Required) MM slash DD slash YYYY Are you willing to travel?(Required) Yes No If YES, any restrictions? Yes No Work Availability(Required) Full Time Part Time Shift Work Are you willing to relocate?(Required) Yes No If Yes, any restrictions to relocating? Drivers License Number State Issued Expiration Date MM slash DD slash YYYY Class Last 4 digits of Social Security Number (123-45-XXXX) Employment HistoryPresent or Last EmployerMay we Contact your current employer for a reference?(Required) Yes No Hours per weekCompany Name From (month/year) MM slash DD slash YYYY To (month/year) MM slash DD slash YYYY City and State Phone (with area code)Type of Business Ending SalaryPosition Title Reason for Leaving Name of Supervisor Title of Supervisor Supervisor's Phone no.2nd Previous EmployerMay we contact for a reference? Yes No Hours per weekCompany Name From (month/year) MM slash DD slash YYYY To (month/year) MM slash DD slash YYYY City and State Phone (with area code)Type of Business Ending SalaryPosition Title Reason for Leaving Name of Supervisor Title of Supervisor Supervisor's Phone no.3rd Previous EmployerMay we contact for a reference? Yes No Hours per weekCompany Name From (month/year) MM slash DD slash YYYY To (month/year) MM slash DD slash YYYY City and State Phone (with area code)Type of Business Ending SalaryPosition Title Reason for Leaving Name of Supervisor Title of Supervisor Supervisor's Phone no.4th Previous EmployerMay we contact for a reference? Yes No Hours per weekCompany Name From (month/year) MM slash DD slash YYYY To (month/year) MM slash DD slash YYYY City and State Phone (with area code)Type of Business Ending SalaryPosition Title Reason for Leaving Name of Supervisor Title of Supervisor Supervisor's Phone no.5th Previous EmployerMay we contact for a reference? Yes No Hours per weekCompany Name From (month/year) MM slash DD slash YYYY To (month/year) MM slash DD slash YYYY City and State Phone (with area code)Type of Business Ending SalaryPosition Title Reason for Leaving Name of Supervisor Title of Supervisor Supervisor's Phone no.Military ServiceComplete if you have ever served in any branch of the US Military.Branch Final Base, City & State where assigned Date Entered MM slash DD slash YYYY Date Discharged MM slash DD slash YYYY Rank & Position at Discharge Name of Supervisor Title of Supervisor Supervisor's Phone no.Did you receive a dishonorable discharge? Yes No EducationName of High School, City and State Degree Received Year Received Major and Minor Fields of Study Name of College, City and State Degree Received Year Received Major & Minor Fields of Study Other Education, City and State Degree Received Year Received Major & Minor Fields of Study Additional QualificationsProfessional licenses, registrations, or certifications. List, including state of issuance and expiration dateLanguages in which you are fluent other than English Additional skills or abilities Professional ReferencesName City & State PhoneOccupation Name City & State PhoneOccupation Name City & State PhoneOccupation Applicant CertificationUpload Resume and/or DocumentationMax. file size: 300 MB.The information contained in this application for employment with Child Care Services Association (hereinafter, “The Agency”) is true to the best of my knowledge and belief. 1) I understand that any misrepresentation or false statement made by me in connection with the application or any related documents that are deemed material by The Agency shall result in The Agency not employing me or, if employed, terminating my employment. 2) I understand and agree that all information furnished in my application and any attachments may be verified by The Agency or its authorized representative. I hereby authorize all individuals and organizations named or referred to in my application and any law enforcement organization to give The Agency all information relative to such verification and hereby release such individuals, organizations, and The Agency from any and all liability for any claim or damage resulting therefrom. 3) I hereby acknowledge that I have been informed by The Agency that The Agency may seek to obtain a consumer report and/or investigative report that will include personal information regarding me, including but not limited to, educational history, work references, driving record and criminal convictions or arrest records if allowed, in order to assist The Agency in making certain employment decisions. I hereby consent to permit The Agency to conduct a search of state criminal history information and a fingerprint-based FBI check (if necessary) for selection and compliance purposes. I understand that selection into the program is contingent upon successful clearance of these checks and a search of the National Sex Offender Public Website. I understand that if I have been convicted of murder of if am being required to be registered as a sex offender I am ineligible to work or serve in this position. 4) I further acknowledge notification by The Agency that reports may be provided to The Agency by other firms subcontracted for that purpose. I, my heirs, assigns and legal representatives, hereby release and fully discharge The Agency, its parent and affiliated companies and the respective officers, directors, shareholders, employees, agents of each, including subcontractors, from any and all claims, monetary or otherwise, that I may have against The Agency, its parent, affiliates or subcontractors, arising out of the making, or use of, either a consumer report and/or investigative report, including any errors or omissions contained or omitted from such reports or investigations. The Agency agrees to inform you if an employment decision has been influenced by information contained in a consumer report. The Agency will make available to you “A Summary of Your Rights Under The Fair Credit Reporting Act.” Consent I agreeSignatureDate MM slash DD slash YYYY CAPTCHA