Fillable Printable Application for employment or volunteer
Fillable Printable Application for employment or volunteer
Application for employment or volunteer
10.9.4.9 CC Employment Application 4/2009
1
Application for Employment or Volunteer Services
Licensed/Certified Child Care Agency
INSTRUCTIONS
PURPOSE
The purpose of the Application For Employment or Volunteer Services, Licensed/Certified Child Care Agency, DEL
10.9.2.13, is to assist the agency director in putting together information which would be necessary in making decision
about hiring and to assist in checking the background of applicants who will have access to children. The form does not
contain all the information desired by some agency directors. Directors may supplement this form as they see fit.
Agencies may be granted approval by the Department of Early Learning (DEL) offices to use their own forms provided
that those forms include essentially the same background information regarding employment history, volunteer history,
educational background, references, and such.
USE OF FORM
The DEL 10.9.2.13 is used by all licensed/certified agencies.
In accordance with WAC 170-151-470
"Each employee and volunteer having unsupervised or regular access to the child in care shall complete and submit to the
licensee or director by the date of hire: (a) An application for employment on a department-prescribed form, or its
equivalent."
OR
In accordance with WAC 170-295-7050 (1) (a): (1)
“Each employee and volunteer who has unsupervised access to a child in care must complete the following forms on or
before their date of hire: (a) An application for employment on a form prescribed by us, or on a comparable form
approved by the department.”„
INSTRUCTIONS TO AGENCY
All licensed/certified agencies are to have each employee, assistant, or volunteer who has unsupervised access to children,
expectant mothers, or developmentally disabled persons complete this form.
Retain a copy of the completed form in the agency's personnel files.
10.9.4.9 CC Employment Application 4/2009
2
Application for Employment or Volunteer Services
Licensed/Certified Child Care Agency
1. Name of Agency
2. Position for which you are applying
3. Date
4. Your Name
5. Are you 16 years or
older? Yes No
6. Social Security Number
7. Your Home Address
8. Telephone Number
9. Days and hours you are willing to work
10. Expected Salary
11. Do you have a current: YES NO
Washington Food Service Worker permit?
(required of all staff persons preparing full meals per WAC 170-151-250 & WAC 170-295-3170)
HIV/AIDS training card?
Tubercular test result (Mantoux method)?
(required of all staff persons having regular contact with children per WAC 170-151-220 & WAC 170-295-110)
Multimedia standard first aid card?
Infant-Child Cardiopulmonary Resuscitation (CPR) card?
(required of all staff persons having regular contact with children per WAC 170-151-200 & WAC 170-295-1100)
12. Education:
a. High school graduate or General Education Development (GED) test passed? Yes No
b. Early childhood education course work in high school? Yes No
c. Post high school training (college, business school, military, etc.): Yes No
Name and Location
Dates
Attended
Credits
Earned
Did you
Graduate?
Degree/Date
Major/Subject
13. Conferences/workshops you have attended related to job duties:
Title of Conference/Workshop
Clock
Hours
Trainer or Sponsor
14. Training and Special Skills
15. Courses in Early Education
10.9.4.9 CC Employment Application 4/2009
3
16. Employment history (start with current or most recent employer, include volunteer experience):
Employed by: Telephone #:
From Mo/Yr:
Address City State Zip code
To Mo/Yr
Duties/Responsibilities
Total time employed
Hour Per Week
Last Salary
Reason for Leaving
Supervisor‟s Name
Employed by: Telephone #:
From Mo/Yr:
Address City State Zip code
To Mo/Yr
Duties/Responsibilities
Total time employed
Hour Per Week
Last Salary
Reason for Leaving
Supervisor‟s Name
Employed by: Telephone #:
From Mo/Yr :
Address City State Zip code
To Mo/Yr
Duties/Responsibilities
Total time employed
Hour Per Week
Last Salary
Reason for Leaving
Supervisor‟s Name
If more space is needed to write your employment history, attach another sheet of paper or your resume.
17. May we contact your present employer?
Yes No
Name
Address
Telephone Number
19. I certify that the above is true and correct to the best of my knowledge. I understand that untruthful or misleading
answers are cause for rejection of my application or dismissal if employed. I authorize an investigation of statements
contained in this application which will allow the employer to make an employment decision.
Your Signature
Date
