Minnieland Academy - Employment Application

Preferred Location:
Date of Application:

All applicants will be considered for employment without regard to race, religion, color, gender, national origin, age, marital or veteran status, medical condition or handicap, or any other status protected by the law. Minnieland is an Equal Opportunity Employer.

Position Applied For:

Full Time

Part Time

Expected Salary per hour:

Expected Salary per year:

Email Address:

Personal Data

Name (last, first, middle)

Address

City

State

Zip Code

Home Phone

Cellular Phone

Are you at least 18 years of age?

Date you are available for work?

select

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If requesting part time, list hours available (Staff must work the same hours Monday-Friday)

Have you worked for us before?

select

Where?

In what position?

When?

Education

Select the highest grade level completed:

select

Name and location of high school:
Do you have a high school diploma?

select

If you did not complete high school, do you have a high school equivalency diploma?

select

Select the number of years of education past high school:

select

Name and location of School/College/University:

Date attended	Hours	Degree received
Specialty	Minor

If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date:

First Aid Certification:

select

Expiration Date:

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CPR Certification:

select

Expiration Date:

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Experience

Starting with your most recent job, describe all paid positions.

1. Job Title

Salary

Employer

Address

Phone

Type of Business

Immediate Supervisor

Dates of employment
(from)

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(to)

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Type:

select

Hours per week:
Job Duties:

May we contact your employer for a reference:

select

2. Job Title

Salary

Employer

Address

Phone

Type of Business

Immediate Supervisor

Dates of employment
(from)

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(to)

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Type:

select

Hours per week:
Job Duties:

May we contact your employer for a reference:

select

3. Job Title

Salary

Employer

Address

Phone

Type of Business

Immediate Supervisor

Dates of employment
(from)

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(to)

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Type:

select

Hours per week:
Job Duties:

May we contact your employer for a reference:

select

In narrative form, describe your special skills, talents, volunteer work or training that would help us evaluate your application.

Reference

List names, addresses, and relationships to you of three people (not related to you) whom we may contact for information about your qualifications.

1. Name/Title	Company	Work Phone
Address	City	State
Zip	Relationship to you

2. Name/Title	Company	Work Phone
Address	City	State
Zip	Relationship to you

3. Name/Title	Company	Work Phone
Address	City	State
Zip	Relationship to you

Miscellaneous Data

Have you ever been convicted of an offense (excluding minor traffic violations)?
select
Please select a response
Yes
No
If you are hired, you will be required to have a criminal records background check. Is this acceptable to you?
select
Please select a response
Yes
No
Is there anything that would interfere with your ability to successfully perform the duties of this position?
select
Please select a response
Yes
No
If yes, please specify:

List person to be contacted in case of emergency:

Name
Address
Phone

Sworn Disclosure Statement

Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth or equivalent offense outside the Commonwealth?

select

If yes or pending, specify crime(s):

select

If yes or pending, specify crime(s):

Have you ever been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth?

select

If yes or pending, specify state, or other location:

Text Version of Resume (optional):

I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.

I hearby affirm that the above information is true and complete to the best of my knowledge. I understand that it may be subject to verification. Should I be employed by Minnieland, any misrepresentation or false statement made on this application may be considered cause for possible dismissal. Minnieland has my permission to obtain all necessary information from the references I have listed concerning my prior employment. I release all parties from any possible damages resulting from disclosing such information with or without prior written notice from me.

If hired, I understand this application is not considered a contract. In the Commonwealth of Virginia, I am considered an at will employee and may be terminated by Minnieland Private Day School, Inc. at any time.

Applications Signature (This application is valid for 60 days)

Date:

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