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Positions you are applying for,
in order of preference

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Form must be completed, then signed and dated
at the bottom.

SVPDA is an Equal Opportunity Employer and does not discriminate against any applicant for employment because of race, color,
religion, creed, sex, national origin, age, disability, marital or Veteran status, sexual orientation, or any other legally protected status.

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Sequatchie Valley
Head Start

Employment History: List last or present employer first. Note reason for any gaps in employment.

Name, Address, and Phone # of Supervisor & Employer

Dates Employed

Position

Reason for Leaving

If presently employed, may we contact your employer?

Have you ever been fired from a position or resigned in order to avoid being fired?

References: List below the names of three persons not related to you who have known you for at least one year.

Name, Address, and Phone #

Occupation / How Known

Years Known

College(s)

Trade, Business
or Other Schools

High School(s)

Education History:

Name and Address

# Years Attended

Indicate GED, diploma or degree (with major)

A declaration will be required related to all pending and prior criminal arrests and charges related to child abuse, any convictions related to other forms of child abuse and neglect, and all convictdions for violent felonies. The declaration form has specific exclusions, and the Agency will review any application on an indivdiual basis in order to assess the relevancy of any arrest, pending criminal charges, or convictions.

Have you ever been convicted of a felony, including any involving a suspended sentence?

Have you ever been reported for child abuse or neglect?

Have you ever had a positive drug test related to employment?

Any or all DOT drug / alcohol employment test results will be requested from former employers.

I hereby certify that all statements made herein and attached hereto are true to the best of my knowledge and belief, and I know that any falsehood or misrepresentation later disclosed will be sufficient grounds for loss of employment. I understand and agree to a pre-employment physical examination which will incude a drug test, and understand that random drug / alcohol tests are required for some positions. I hereby authorize SVPDA to investigate and vertify all statements made in this application and to conduct any further investigation it deems necessary to determine my suitability for volunteer service or employment. I release SVPDA and its agents from any liability in connection with such an investigation.

Submit form by clicking "Submit" button at top AFTER signing and dating.

Applicant's Signature  _______________________________________________________________________                  Date __________________________