Name
*
First Name
Last Name
Phone Number
*
Email Address
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
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Head Start
Please check all positions you would be willing to accept.
How did you learn about this position?
Do you have family members employed by DAEOC?
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Yes
No
If so, who?
Were you previously employed by DAEOC?
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Yes
No
If yes, list the dates you were hired and the position(s) you worked:
Are you legally eligible for employment in the United States?
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Do you have a valid driver's license in Missouri?
*
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Yes
No
Have you lived in any other state(s) besides Missouri within the past 5 years?
*
Select One
Yes
No
If yes, please list other state(s)
Have you ever been reported and/or convicted of Child Abuse or Neglect
*
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Yes
No
If yes, please explain:
Do you have a High School diploma?
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Yes
No
Name of school (High School)
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School address
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State/Province
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Last year completed
*
Diploma/Degree
Name of school (Post-Secondary)
School address
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Last year completed
Diploma/Degree
Name of school (Post-Secondary)
School address
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Last year completed
Diploma/Degree
If necessary, please list other relevant schools, skills and qualifications:
Name of business
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Are you still employed at this position?
Yes
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Business address
Address 1
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State/Province
Zip/Postal Code
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Phone
(###)
###
####
Supervisor
First Name
Last Name
May we contact this supervisor?
Description of duties:
Name of business
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Business address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number
(###)
###
####
Supervisor
May we contact this supervisor?
Description of duties:
Name of business
Start Date
MM
DD
YYYY
End Date
MM
DD
YYYY
Business address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number
(###)
###
####
Supervisor
May we contact this supervisor?
Description of duties:
Personal or Professional?
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Personal
Professional
Name
*
First Name
Last Name
Phone number
(###)
###
####
Address
*
Address 1
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City
State/Province
Zip/Postal Code
Country
Personal or Professional?
*
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Personal
Professional
Name
*
Phone number
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
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Personal or Professional?
*
Select one
Personal
Professional
Name
*
Phone number
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
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Please read the following:
*
I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I
understand that any false statement, omission or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been
employed, no matter when discovered by DAEOC. I understand that any employment is conditioned on a background check. I authorize DAEOC to
thoroughly investigate all statements in my application or resume and I authorize my former employers and reference to disclose information regarding
my former employment, character and general reputation to DAEOC, without giving me prior notice of such disclosure. In addition, I release DAEOC,
any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or
disclosure.
I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment
contract. I further understand and agree that if I am hired, my employment with be “at will” and without fixed term, and may be terminated at any time,
with or without cause and without prior notice, at the option of either DAEOC or myself. No promises regarding employment have been made to me and
I understand that no such promise or guarantee is binding upon DAEOC unless made in writing.
If I am offered employment I agree to submit to a pre-employment drug-screening test before starting work. If employed, I also agree to submit
to a medical examination and/or drug test at any time deemed appropriate by DAEOC and as permitted by law. I consent to such examination and tests
and I request that the examining doctor disclose to DAEOC the results of the examination, which results shall remain confidential and segregated from
my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical
examinations and drug test and, if I am hired, a condition of my employment will be that I abide by DAEOC’s Drug and Alcohol Policy, Work Rules and
Personnel Policies and Procedures. DAEOC retains the right to revise its policies and procedures manual in whole or in part at any time. This application
for employment shall be considered active for a period of six months. Any applicant wishing to be considered for employment beyond this time period
should complete a new application.
Benefits will be offered as outlined in the Personnel Policies and Procedures. Benefits become active for eligible staff persons at the beginning of
the calendar month following the first day of employment.
By checking the box below, I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions
