Saint Louis Crisis Nursery, Regional Administrative Offices

11710 Administration Drive, Suite 18

St. Louis, MO 63146

Phone: 314-292-5770

Fax: 314-292-5776

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, genetic information, marital or veteran status, or any other legally protected status. Federal law requires us to provide reasonable accommodation for known disabilities, unless to do so would pose an undue hardship. Please let us know if you need an accommodation to complete the application process.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Date of Application: How did you hear about this position?

Last Name: First Name:

Middle Initial: Maiden Name:

Address:

City: State: Zip Code:

Position Applying For:

Desired Starting Pay:

Phone (With Area Code): Cell Other

Email address:

Availability:Full TimePart TimeDate available to start work:

Days Afternoons Evenings Weekend Shifts Overnight

Please rate each of the following regarding their importance to you:

(5 = very important; 4 = important; 3 = moderately important; 2 = of little importance; 1 = unimportant)

Flexibility Energy Level Teamwork Communication Strengths-based Perspective

Choose best location(s) for you: St.L City St.L South County St.L North County St. Charles City Wentzville

Are you at least 21 years old? YesNo (a Division of Children’s Services Requirement)

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

YesNo(Proof of citizenship or immigration status will be required upon employment)

Have you ever been convicted of a crime other than a minor traffic violation? YesNo

If yes, please explain (a conviction will not necessarily disqualify an applicant):

EDUCATION AND TRAINING

Name of High School: / Diploma or GED
Name of College/University: / Degree: Yes No In Process
Major Field of Study/Degree:
Additional training, memberships or skills:

EMPLOYMENT EXPERIENCE – List Present Job First

Employer: / Dates Employed
From
To / Reason for Leaving:
City, State, Zip:
Telephone:
Your Job Title:
Wage: / May we contact your Employer? Yes No
Employer: / Dates Employed
From
To / Reason for Leaving:
City, State, Zip:
Telephone:
Your Job Title:
Wage: / May we contact your Employer? Yes No
Employer: / Dates Employed
From
To / Reason for Leaving:
City, State, Zip:
Telephone:
Your Job Title:
Wage: / May we contact your Employer? Yes No

Please explain any gaps in employment:

From toComments:

From to Comments:

APPLICANT’S STATEMENT: PLEASE READ THIS STATEMENT CAREFULLY, SIGN AND DATE BELOW.

YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE IF NOT SIGNED AND DATED.

This document serves solely as a clear and conspicuous written disclosure as required by the Federal Fair Credit Reporting Act set forth in Section 604(b) to the Applicant that previous employment, education, social security, credit, motor vehicle report, and a criminal background check may be obtained for the purpose of this employment application only. Your signature below acknowledges that the Saint Louis Crisis Nursery has made this disclosure.

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application, as well as information concerning me from my present (unless otherwise indicated by me) and former employers as may be necessary in arriving at an employment decision.

I authorize my employer or potential employer to investigate, obtain, compile, examine, copy, or receive any records pertaining to my employment history and completely and without reservation allow my employer to release and/or discuss any information about my employment history with authorized personnel of the Department of Social Services. I further authorize the Department of Social Services to share any personnel information that the Department of Social Services may have about me with my employer or prospective employers as the Department determines necessary to make personnel decisions regarding my suitability to provide services with my employer. By authorization of the above, I agree to hold harmless any individual, partnership, corporation, educational institution, or agency, The Department of Social Services, the Missouri Children’s Division, it’s officers, agents and employees, as well as the State of Missouri, from any liability for any damage whatsoever for issuing such information.

This application contains no misrepresentation or falsifications and the information given is true and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification as to a material fact, the application will be rejected or, if selected, I may be dismissed by the employer/contractor.

Print Name: Date:

Signature of Applicant:

9/2015

Invitation to Self-Identify

PLEASE READ CAREFULLY BEFORE COMPLETING THIS FORM

Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin.

This employer is subject to certain nondiscrimination recordkeeping and reporting requirements that require the employer to invite employees to voluntarily self-identify their gender and race/ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable federal laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement purposes.

If you choose not to self-identify your gender or race/ethnicity at this time, the federal government requires this employer to determine this information by visual survey and/or other available information.

For civil rights monitoring and enforcement purposes only, all gender and race/ethnicity information will be collected and reported in the categories identified below. If you choose to voluntarily self-identify, you may mark only one of the boxes presented for gender and only one of the boxes presented for race/ethnicity.

What is your gender?☐Male☐Female

What is your race/ethnicity? Please mark the one box that describes the race/ethnicity category with which you primarily identify.

☐ Hispanic or Latino

☐ White

☐ Black or African American

☐ Asian

☐ Native Hawaiian or Other Pacific Islander

☐ American Indian or Alaska Native

☐ Two or More Races

9/2015