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:
*
Teacher - LIFES Academy
Date
*
Where did you see this job ad?
*
Last Name:
*
First Name:
*
M.I.
E-mail
*
Primary Phone
*
Primary Phone Type:
*
Home
Cell
Alternate Phone
Street Address
*
Apartment/Unit #
City
*
State
*
Zip
*
Education
*
Did you graduate high school or do you have a high school equivalency diploma?
YES
NO
(If No:) Highest Grade completed?
1
2
3
4
5
6
7
8
9
10
11
12
Number of years of post-high school education:
0
1
2
3
4
5
6
7
8
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
Add Institution
Remove
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
Add License
Remove
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
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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.
Experience #2
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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.
Experience #3
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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.
Experience #4
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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.
Experience #5
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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.
Experience #6
Job Title
*
Employer
*
Address
*
Phone
*
Type of Business
*
Hours worked per week
*
Duties
*
Reason For Leaving
*
Date Start (mo/yr)
*
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
Remove
Miscellaneous
*
Have you ever been discharged, forced to resign, or failed to have an employment contract renewed?
YES
NO
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?
YES
NO
Please list name, relation, and their title:
*
Do you have any relatives working for Step?
YES
NO
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:
*