Job Application

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Application Information:

Name:

Date:

Phone:

Email:

Have you ever worked for this company?

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Date Available:

Position Applied For:

Do you have a valid KY Driver's License?

Are you a citizen of the United States?

Have you ever been convicted of a crime or felony or have any current crime or felony charges pending against you?

If Yes, please explain:

Do you have any pending and /or prior criminal arrest and charges related to child sexual abuse?

If yes, please explain:

Do you have any pending and/or prior convictions related to other forms of child abuse and /or neglect?

If yes, please explain:

Are you, or have you been, a parent in Head Start Preschool or Early Head Start?

Were you a child in Head Start Preschool or Early Head Start?

Are you related to anyone employed with BGP?

Are you related to any BGP's Board or PC Members?

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Education:

High School:

City,State

Did you graduate?

If not, do you have a GED?

College:

City, State

Did you graduate?

Currently enrolled?

Degree:

Other:

City, State:

Did you graduate?

Degree:

Field label

References:

Please list three personal references (Not related to you)

Full Name:

Relationship:

Phone:

Full Name:

Relationship:

Phone Number

Full Name:

Relationship:

Phone Number:

Field label

Please list three professional references:

Full Name:

Company:

Phone Number:

Full Name:

Company:

Phone Number:

Full Name:

Company:

Phone Number:

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Previous Employment:

Company

Phone Number:

Supervisor:

Job Title:

From:

To:

Responsiblities:

May we contact your previous supervisor for a reference?

Company:

Phone Number:

Supervisor:

Job Title:

From:

To:

Responsibilities

May we contact your previous supervisor for a reference?

Company

Phone Number:

Supervisor:

Job Title:

From:

To:

Responsibilties:

May we contact your previous supervisor for a reference?

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Military Service:

Branch:

From:

To:

Rank at discharge:

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Disclaimer and Acknowledgments:

I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information provided may result in the rejection of my application or, if employed, termination of employment.

I understand and acknowledge that Kentucky Child Care and Head Start regulations mandate Criminal Record Checks, Child Abuse & Neglect Check, Sex Offender Registry Check, and fingerprint check as conditions of employment and that employment is contingent upon the acceptance of the results by Breckinridge-Grayson Programs, Inc., as well as Policy Council and Board approval.

I understand that all employees must complete a pre-employment physical examination, drug screen and a Tuberculosis (Tb) assessment or skin test once a hiring determination is made and prior to beginning work.

For positions requiring a commercial driver's (CDL) or other certifications, I understand that I must obtain and maintain the required licensure of certification to continue employment with Breckinridge-Programs, Inc.

I understand that Breckinridge-Grayson Progams, Inc., is an Equal Opportunity Employer (EOE) and does not discriminate based on race, color, religion, sex, national origin, disability, or any other protected category.

By signing below, I confirm that I have read and understood the terms outlined in this disclaimer.

Signature:

Date: