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: *
LIFES Academy Behavior Intervention Paraprofessional
Date *
Where did you see this job ad? *
Last Name: *
First Name:*
M.I.
E-mail *
Primary Phone *
Primary Phone Type: *
Alternate Phone
Street Address *
Apartment/Unit #
City *
State *
Zip *

Education

* Did you graduate high school or do you have a high school equivalency diploma?
(If No:) Highest Grade completed?
Number of years of post-high school education:
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Did you complete your degree?

License

License (to include drivers), certificate, or other authorization to practice a trade or profession:
Type
License Number
Expiration Date
Granted By
Type
License Number
Expiration Date
Granted By
Type
License Number
Expiration Date
Granted By

References

Please list three professional references.

Full Name *
Address *
Phone *
Relationship *
Email *
Full Name *
Address *
Phone *
Relationship *
Email *
Full Name *
Address *
Phone *
Relationship *
Email *

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

Duties *
Reason For Leaving *

    Immediate Supervisor


Experience #2

Duties *
Reason For Leaving *

    Immediate Supervisor


Experience #3

Duties *
Reason For Leaving *

    Immediate Supervisor


Experience #4

Duties *
Reason For Leaving *

    Immediate Supervisor


Experience #5

Duties *
Reason For Leaving *

    Immediate Supervisor


Experience #6

Duties *
Reason For Leaving *

    Immediate Supervisor



Miscellaneous

* Have you ever been discharged, forced to resign, or failed to have an employment contract renewed?
Please Explain:

* 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?
Please list name, relation, and their title:
* Do you have any relatives working for Step?
Please list name, relation, and their title:
* 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 *
Date: *