Easter SealsSouth Carolina
Employment Application
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Date: ______Position Applying for: ______
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Last Name First Name Middle Initial Phone Number
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Current Street Address CityState Zip Code
How long have you lived at this address: ______
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Previous Street Address CityState Zip Code
How long did you live at this address: ______
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Social Security #Email address
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Date available to start
Type of employment desired: full time part time temporary
Have you been convicted of a crime? YesNo
If yes, please explain: ______
Have you ever been employed with Easter Seals? Yes No
If yes please indicate when, where, and the position that you held with Easter Seals. ______
Are you authorized to work in the United States? YesNo
Employment History
Most recent
Date of Hire from: ______to: ______
Employer:______
Address: ______
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Position: ______
Immediate Supervisor: ______
Nature of work and responsibilities: ______
Reason for leaving: ______
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Hourly rate/Salary: ______
May we contact this employer: yes no
Date of Hire from: ______to: ______
Employer:______
Address: ______
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Position: ______
Immediate Supervisor: ______
Nature of work and responsibilities: ______
Reason for leaving: ______
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Hourly rate/Salary: ______
May we contact this employer: yes no
Date of Hire from: ______to: ______
Employer:______
Address: ______
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Position: ______
Immediate Supervisor: ______
Nature of work and responsibilities: ______
Reason for leaving: ______
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Hourly rate/Salary: ______
May we contact this employer: yes no
We require one year of experience in thefield of early childhood education,OR one year experience working with infant and toddlers, OR one year experience with children age birth to 5 years with disablilities. Please tell us any experiences you have in this area: ______
Education:
Name of College: ______Date of Graduation: ______
Degree: ______
Name of College: ______Date of Graduation: ______
Degree: ______
References:
Name: ______
Address: ______
Phone #: ______
Occupation: ______
Relationship to applicant: ______
Name: ______
Address: ______
Phone #: ______
Occupation: ______
Relationship to applicant: ______
Name: ______
Address: ______
Phone #: ______
Occupation: ______
Relationship to applicant: ______
Authority to Release Information:
By my signature, I consent to the release of information to Easter Seals South Carolina, which may include but not be limited to information regarding my past and present work, education, law enforcement records, Department of Social Services registry check, and/or any personnel records deemed necessary.
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Signature of ApplicantDate
Certification of Applicant:
By my signature I affirm, agree, and understand that all information on this form are true and accurate. Any misrepresentation, falsification, or material omission of information or data on the application may result in exclusion from further consideration or if hired, termination of employment. If I have requested herein that my present employer not be contacted, an offer of employment may be conditioned upon acceptable information and verification from such employer prior to beginning work.
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Signature of ApplicantDate
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