Please complete all pages of this application even if you are submitting a Resume. Do not fill in blanks with “See Resume.”

Position you are applying for:

Date

YYYY

PERSONAL DATA

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Are you eligible for employment in the United States?

Yes

Date you're available for employment:

YYYY

How did you hear about the job opening?

Newspaper

JobNet

Friend

TechConnect

Are you a past or current Head Start parent?

Yes

Are you related to a Head Start Board Member?

Yes

Are you related to a current Head Start employee?

Yes

If yes, please provide their name:

Are you interested in:

Full-Time

Part-Time

Full or Part-Time

Program Sub

Skills

Do you have a drivers license?

Yes

Licenses/Certifications (please list)

Foreign Languages & Skill Level (please list)

Computer Skills

Please list which software you're skilled with. Example: Microsoft Word 2007, Excel, Publisher, etc)

EDUCATION

Do you have a High School Diploma or GED?

Required for employment.

Yes

List education i.e. Colleges, Technical College, Trades, or any other schools attended that meet the requirements of the job you are applying for.

Name & Location of School (1)

Course of Study

Credits Earned

Dates Attended

Graduate

Yes

Degree Attained

Name & Location of School (2)

Course of Study

Credits Earned

Dates Attended

Graduate

Yes

Degree Attained

Name & Location of School (3)

Course of Study

Credits Earned

Dates Attended

Graduate

Yes

Degree Attained

WORK EXPERIENCE

Name & Address of Employer (1)

Supervisors Name & Phone Number

May we contact this employer?

Yes

Start Date

YYYY

End Date

YYYY

Wages/Beginning

Wages/Ending

Titles/Duties

Reason for Leaving

Name & Address of Employer (2)

Supervisor Name & Phone

May we contact this employer?

Yes

Start Date

YYYY

End Date

YYYY

Wages/Beginning

Wages/Ending

Titles/Duties

Reason for Leaving

Name & Address of Employer (3)

Supervisor Name & Phone

May we contact this employer?

Yes

Start Date

YYYY

End Date

YYYY

Wages/Beginning

Wages/Ending

Titles/Duties

Reason for Leaving

REFERENCES

Name of Reference (1)

Relationship

Business

Professional

Years Acquainted

Phone

(###)

###

####

Name of Reference (2)

Relationship

Business

Personal

Years Acquainted

Phone

(###)

###

####

Name of Reference (3)

Relationship

Business

Personal

Years Acquainted

Phone

(###)

###

####

Name of Reference (4)

Relationship

Business

Personal

Yearfs Acquainted

Phone

(###)

###

####

Please include any previous experience you've had with Head Start.

COMMUNITY/VOLUNTEER EXPERIENCE

Name & Address of Organization (1)

Contact Person

Phone

(###)

###

####

Hours per Month

Years Involved

Title/Duties Performed

Name & Address of Organization (2)

Contact Person

Phone

(###)

###

####

Hours per Month

Years Involved

Title/Duties Performed

Name & Address of Organization (3)

Contact Person

Phone

(###)

###

####

Hours per Month

Years Involved

Title/Duties Performed

Please provide any additional information you wish to share that relates to the job opening you are applying for.

1) I understand that documentation and employment eligibility for compliance with the US Immigration Control and Reform Act is required at the time of hire. 2) I understand that I am required to provide Tuberculin Test results at the time of hire. 3) I understand that enrollment in the Dept of Justice online records check is required at the time of hire and must be renewed as required by daycare licensing thereafter. 4) I hereby give my consent to Sheboygan County Head Start to contact previous employers, unless otherwise noted on the application, for purposes of verification of employment and employment references. 5) I understand that my being hired is contingent upon final approval by Head Start Policy Council. 6) I hereby certify that the facts set forth in the foregoing employment application are true and complete to the best of my knowledge. 7) I understand, if I am employed, that falsified, incomplete or misleading statements on this application will result in my dismissal. 8) I understand that due to the nature of Head Start, it is important to know that wages and hours are subject to change based on the availability of Federal and State Funding. 9) I understand that if I terminate employment within 90 days of hire I will reimburse Head Start the cost of my TB Test and Physical. This will then be deducted from my last paycheck.

Electronically Sign

Date

YYYY

Birthdate

YYYY

Social Security Number

(Criminal Background Check will be done on Wisconsin Dept of Justice Check System)

Thank you for submitting an application for employment.

We will review your qualifications and contact you should your qualifications meet our job requirements.

Careers

Custodian

Sheboygan County
Head Start

Careers

Custodian

Sheboygan CountyHead Start

Sheboygan County
Head Start