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Staff Application Form

Staff Application Form

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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 _________________________

Education

School Years Attended________________________

Name of School_____________________________

City & State________________________________

Course/Degree/Hours_________________________

High School ________________________________

College____________________________________

Other Child_________________________________

Care Training________________________________ 

Experience

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.     

 Yes____                  No____

I have received and read the DYFS Information to Parents Document.

 Yes____ No____ 

I have received and read the center’s policy on the disciplining of children.

 Yes____ No____ 

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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