Staff Application Form

10:122-4.1 General requirements for sponsor, director and all staff members
May be completed by applicants for staff positions at the center
Staff information/application form
Name__________________________________________ Telephone_______________________ Address ________________________________________ City _________________________ State _________ Zip_____________
Birth date (if under 18 years) ___________________
Position applying for _________________________
School Years Attended________________________
Name of School_____________________________
City & State________________________________
Course/Degree/Hours_________________________
High School ________________________________
College____________________________________
Other Child_________________________________
Care Training________________________________
Name & Address of Employer_____________________
Dates________________________________________
Job Duties_____________________________________
From_________________________________________
To___________________________________________
Have you ever been convicted of a crime or a disorderly persons offense? ________Yes _________No
If yes, please describe____________________________________
____________________________________________________
I have received a Child Abuse Record Information (CARI) form and given permission for a CARI check.
I have received and read the DYFS Information to Parents Document.
I have received and read the center’s policy on the disciplining of children.
I attest that the above information is correct.
Signature_____________________________________ Date____________________________
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For center use only: Social Security # ____________________________________
Date hired_______________________________ Date terminated___________________________
Date of physical___________________________________
Results_________________________________________
Date of Mantoux/chest X-ray_________________________ Results_________________________________________
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