Assistant Director Application Url Last Name * Address * First Name * City * Middle Name State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Maiden (if applicable) Zip Code * Contact Number * Driver's License Number * Date of Birth * Expiration Date of Driver's License * EDUCATION: EDUCATION Elementary High School College Graduate Other School/Institution _ _ _ _ _ Dates Attended _ _ _ _ _ Diploma/Degree/Certificate _ _ _ _ _ Title of course/Workshop/conference _ _ _ _ Sponsor/Location _ _ _ _ Date(s) _ _ _ _ Number of hours _ _ _ _ EMPLOYMENT HISTORY List in order beginning with your most recent employment. Employer Employer's Address Position/Job Date(s) Worked Reason for leaving Employer Employer's Address Position/Job Date(s) Worked Reason for leaving Employer Employer's Address Position/Job Date(s) Worked Reason for leaving REFERENCES: List at least three persons who are not related to you by blood, marriage, or adoption to be contacted as references. At least one must be a former employer. Addresses must be complete and accurate. Name of Former Employer: * Last, First, Middle Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Telephone Number * Name of Former Employer: Last, First, Middle Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Telephone Number Name of Former Employer: Last, First, Middle Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Telephone Number Criminal History Background Information Checks: In accordance with Alabama law, (Code of Alabama 1975, Title 38, Chapter 13, effective November 1, 2000), the criminal history background information check shall be completed on each substitute, caregiver, volunteer, and domestic worker, as well as any other person who has contact with the children or unsupervised access to the children shall be reviewed. You must complete a Mandatory Criminal History Notice Form and a Criminal History Information Consent and Release Form. The fee must be submitted with the fingerprints and the consent form. Required forms are available from the Department. If you previously had a criminal history check done for the Department of Human Resources and the required information is on file, it is not necessary to complete a criminal history check. Current Criminal Charges: Are there any current criminal charges against you? * Yes No If yes, give details Clearance of State Central Registry on Child Abuse/Neglect A completed REQUEST FOR CLEARANCE OF STATE CENTRAL REGISTRY ON CHILD ABUSE/NEGLECT (DHR-DFC-1598) shall be obtained for each caregiver, substitute, volunteer, domestic worker, and any other person who has contact with the children or unsupervised access to the children. By signing this form, I am affirming that the above statements I have made are true and factual to the best of my knowledge; and I am granting permission for all person, organizations, or agencies listed above to be contacted for information regarding my background. Signature (please type name) * Date *
