Please carefully read this application in its entirety before beginning to enter information to ensure that you can provide all necessary information and understand all conditions noted in the final Applicant Statement.  Once submitted, you will not be able to retrieve this application for further additions.  Only fully completed applications will be considered.

If you would like to print a blank application and assemble your information before entering it to this format, click Print.

Equal access to programs, services and employment is available to all persons.  Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

* = required field

* Name First Middle Last * Social Security # -  - 
Have you ever used any other name in the past? Yes No
If yes, please list all other names and dates during which you have used these names:
* Address
* City * State * Zip

* Home Phone # How did you hear of us?

Email Address

Type of work or position applied for? Full Time Part Time

Days Available Hours Available Date Available to Begin Work

Shift Availability (check all that apply)   1st: 6 am-4 pm   2nd: 2:30-10:30 pm/3-11 pm   3rd: 10 pm-8 am  

Salary Requirements $     Are you over 21? Yes No

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Have you ever worked for any agency in the Archdiocese of St. Louis or Catholic Charities? Yes No
Have you been employed by us before? Yes No
Have you applied for employment with us previously? Yes No

If you have relatives employed with us, their name/relationship
If you would be engaged in any other work while in our employ, please explain

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If hired, can you demonstrate eligibility to work in the United States?	Yes No
Have you ever been convicted, pleaded guilty, or plead "no contest" to any crime?	Yes No
If yes, please explain:
Has a former employer ever disciplined you for tardiness or absenteeism?	Yes No
If yes, please explain:
Do you have a valid driver's license?	Yes No
Driver's license number Issuing state Expiration date
After hearing of the job duties, to the best of you knowledge would you be able to perform all the essential functions of this position?	Yes No

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Employment History

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Provide the following information about ALL employers, assignments or volunteer activities, starting with the most recent.

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Employer

Are you currently working for this company?Yes No     If yes, may we contact? Yes No

Address City State Zip

Email     Phone

Supervisor Title

Starting position  Ending position

Employed from  to

Beginning salary Ending salary

Brief job description

Reason for leaving

What did you most like about your position?

What did you like least about your position?

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Employer

Are you currently working for this company?Yes No     If yes, may we contact? Yes No

Address City State Zip

Email     Phone

Supervisor Title

Starting position  Ending position

Employed from  to

Beginning salary Ending salary

Brief job description

Reason for leaving

What did you most like about your position?

What did you like least about your position?

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Employer

Are you currently working for this company?Yes No     If yes, may we contact? Yes No

Address City State Zip

Email     Phone

Supervisor Title

Starting position  Ending position

Employed from  to

Beginning salary Ending salary

Brief job description

Reason for leaving

What did you most like about your position?

What did you like least about your position?

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Employer

Are you currently working for this company?Yes No     If yes, may we contact? Yes No

Address City State Zip

Email     Phone

Supervisor Title

Starting position  Ending position

Employed from  to

Beginning salary Ending salary

Brief job description

Reason for leaving

What did you most like about your position?

What did you like least about your position?

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Employer

Are you currently working for this company?Yes No     If yes, may we contact? Yes No

Address City State Zip

Email     Phone

Supervisor Title

Starting position  Ending position

Employed from  to

Beginning salary Ending salary

Brief job description

Reason for leaving

What did you most like about your position?

What did you like least about your position?

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Explain any gaps in your employment, other than those due to personal illness, injury or disability.

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Educational Background

Starting with your most recent school attended, provide the following information.

Level High School Business / Trade College / Univ School City State

Year Graduated

Degree None GED HS AA LPN RN BA BS MA MS MSW MEd PhD Other Specify

Major

Grade Point

Honors

Level High School Business / Trade College / Univ School City State

Year Graduated

Degree None GED HS AA LPN RN BA BS MA MS MSW MEd PhD Other Specify

Major

Grade Point

Honors

Level High School Business / Trade College / Univ School City State

Year Graduated

Degree None GED HS AA LPN RN BA BS MA MS MSW MEd PhD Other Specify

Major

Grade Point

Honors

Level High School Business / Trade College / Univ School City State

Year Graduated

Degree None GED HS AA LPN RN BA BS MA MS MSW MEd PhD Other Specify

Major

Grade Point

Honors

Level High School Business / Trade College / Univ School City State

Year Graduated

Degree None GED HS AA LPN RN BA BS MA MS MSW MEd PhD Other Specify

Major

Grade Point

Honors

  

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Skills & Qualifications

Computer Skills:	Word Excel Power Point Windows Publisher Other Computer:
Additional Skills:
Languages spoken in addition to English:

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Professional License

Do you have a professional license? Yes No

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References

List name, address and telephone number of three (3) personal references that are not related to you and are not previous supervisors.
All references must have a mailing address.

Name Years Known Title Relationship Address City State Zip Phone Fax Email

Name Years Known Title Relationship Address City State Zip Phone Fax Email

Name Years Known Title Relationship Address City State Zip Phone Fax Email

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Additional Information

List any additional information you would like us to consider:

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Applicant Statement

Please read thoroughly before signing

It is understood that this application is not an obligation of employment.

I hereby authorize the company to investigate all references and former employment, and I release from liability those supplying such information. Upon offer of employment, I may be required to take a drug test at the company's expense and realize that the offer of employments contingent upon my test results being drug-free and appropriate information being received from reference sources. I also grant permission to the Employer to contact, in connection with my application and periodically thereafter if I am employed, the Missouri Division of Family Services and any other governmental agencies, organizations, corporations, entities, or individuals that the Employer deems necessary in order to verify the continued accuracy of any information given in connection with this application and periodically thereafter if I am employed, an and all forms required by the Employer (including, but not limited to, an application for child abuse/neglect screening form to be submitted to the Missouri Department of Social Services). In addition , I release the Employer and all of its agents, as well an any individual or organization and all of their agents who supply written or oral information, regarding myself to the Employer, from any and all liabilities resulting from such investigation or verification. I understand and agree that I may be denied employment or, if I am already employed, that my employment may be terminated based on information, obtained during that investigation or verification .

I will provide proof of my eligibility to work within 3 business days as required by "The Immigration Reform and Control Act of 1986."

I understand that the company can make no guarantee as to the number of hours that I may be assigned from week to week, and any reduction in hours can affect my compensation and benefits. I also understand that I may be required to change days off and schedule hours on a temporary or regular basis in order to continue my employment. Also, I understand that the company reserves the right to transfer me, as business necessitates, and my continued employment may be predicted upon my acceptance of said transfer. I understand that evenings or weekends may be part of any schedule I may be assigned.

I understand that my employment is not governed by any written or oral contract and is considered an "at will" arrangement. l understand that I am free, as in the company, to terminate employment at any time for any reason, so long as there is no violation of applicable Federal or State law. Upon termination of my employment with the Employer , regard less of when, how or why my employment is terminated, and whether such termination is affected by me or by the Employer, I authorize the release of reference information on all aspects of my employment history with the Employer and release the Employer and all its agents from any and all liability resulting from disclosure of information on my employment history.

I state that the information on this application is true and complete. False statements, misrepresentations , or omissions may be cause for cancellations of an employment offer or terminations , even if already employed . I agree that I have read and understand the above acknowledgements and agreements and recognize all of the above conditions of employment. DO NOT CHECK UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

EQUAL OPPORTUNITY EMPLOYER

Child Center-Marygrove (hereinafter referred to as "Employer") provides and promotes equal employment opportunities for all persons without regard to race, color, sex, age, national origin, or citizenship as provided by federal law.

Revised 03-10

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Affirmative Action Voluntary Information

COMPLETION OF INFORMATION BELOW IS VOLUNTARY
We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status.  We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey.  Providing this information is STRICTLY VOLUNTARY.  Failure to provide it will not subject you to any adverse personnel decision or action.  Your cooperation is appreciated.

Please be advised that this survey is not a part of your official application for employment.  It will be maintained separately from your official application.  It will not be used for interview purposes.  It will not be used in any hiring decision.  The information will be used and kept confidential in accordance with applicable laws and regulations.

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Please select one of the following Equal Employment Opportunity Identification Groups

White (not Hispanic or Latino)	Native Hawaiian/Other Pacific Islander (not Hispanic or Latino)
Hispanic or Latino	American Indian/Alaskan Native (not Hispanic or Latino)
Asian (not Hispanic or Latino)	Two or More Races (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)

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Referral Source

Walk-in	Government Employment Agency	Private Employment Agency
Employee	Relative	School
Print Advertisement	Website	Other

If employee referral, please provide their name:

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