200 Dent Street
Rocky Mount, VA 24151
(540) 483-5142
An Equal Opportunity Employer Maintaining a Drug Free Workplace
Application for Employment
Position Applying For:
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LIFES Academy Behavior Intervention Paraprofessional
Date
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Where did you see this job ad?
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Last Name:
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First Name:
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M.I.
E-mail
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Primary Phone
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Home
Cell
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Street Address
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Apartment/Unit #
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Zip
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Education
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Did you graduate high school or do you have a high school equivalency diploma?
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(If No:) Highest Grade completed?
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Number of years of post-high school education:
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Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?
YES
NO
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?
YES
NO
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?
YES
NO
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License
License (to include drivers), certificate, or other authorization to practice a trade or profession:
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Expiration Date
Granted By
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Granted By
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Granted By
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References
Please list three professional references.
Full Name
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Address
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Phone
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Relationship
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Email
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Full Name
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Address
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Phone
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Relationship
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Email
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Full Name
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Address
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Phone
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Relationship
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Email
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Experience
Starting with the most recent, describe all paid, military, and applicable volunteer experience. You may list significantly different jobs within the same organization as separate items.
Experience #1
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
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Date End (mo/yr)
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Ending Salary
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Immediate Supervisor
Name
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Title
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E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Experience #2
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
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Date End (mo/yr)
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Ending Salary
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Immediate Supervisor
Name
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Title
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E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Experience #3
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
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Date End (mo/yr)
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Ending Salary
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Immediate Supervisor
Name
*
Title
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E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Experience #4
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
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Date End (mo/yr)
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Ending Salary
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Immediate Supervisor
Name
*
Title
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E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Experience #5
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
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Date End (mo/yr)
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Ending Salary
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Immediate Supervisor
Name
*
Title
*
E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Experience #6
Job Title
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Employer
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Address
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Phone
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Type of Business
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Hours worked per week
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Duties
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Reason For Leaving
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Date Start (mo/yr)
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Beginning Salary
*
Date End (mo/yr)
*
Ending Salary
*
Immediate Supervisor
Name
*
Title
*
E-mail
I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience.
Please do not contact this supervisor.
Add Experience
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Miscellaneous
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Have you ever been discharged, forced to resign, or failed to have an employment contract renewed?
YES
NO
Please Explain:
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Are you or a member of your immediate family currently a member of the STEP Incorporated Board of Directors or of the STEP Incorporated Head Start Policy Council?
YES
NO
Please list name, relation, and their title:
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Do you have any relatives working for Step?
YES
NO
Please list name, relation, and their title:
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When will you be able to begin work?
Please use this space to provide additional information about your qualifications or to amplify statements made in this application:
I hereby certify that all entries given in this application are true and complete, and I agree and understand that any falsifications of information herein, regardless of time of discovery, may cause forfeiture of my part of any employment in the service of STEP Incorporated, I understand that all information on this application is subject to verification.
Applicant Signature
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Date:
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