JEWISH COMMUNITY CENTER EMPLOYMENT APPLICATION PLEASE RETURN COMPLETED APPLICATION TO: 236 Charlotte St Asheville, NC Attn: HR

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1 APPLICANT INFORMATION Last Name First M.I. Permanent Street JEWISH COMMUNITY CENTER EMPLOYMENT APPLICATION PLEASE RETURN COMPLETED APPLICATION TO: 236 Charlotte St Asheville, NC Attn: HR City State ZIP Apartment/Unit # Today s Home Cell Available for Work: Position Applying For Pay Rate Expected EDUCATION High School College Other EMPLOYMENT HISTORY Supervisor Job Title Starting Salary: $ Ending Salary:$ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO Supervisor Job Title Starting Salary:$ Ending Salary:$ Responsibilities From To Reason for Leaving May we contact your previous supervisor for a reference? YES NO

2 REFERENCES-PROFESSIONAL Please list three professional references: REFERENCES-PERSONAL Please list two personal references. Relationship/Years Known Relationship/Years Known SKILLS AND TALENTS Are there any other experiences, skills or qualifications which you feel would qualify you for work at the Asheville JCC? PERFORMANCE ABILITY Are you a citizen of the United States? YES NO If no, are you authorized to work in the U.S.? YES NO Have you ever been arrested and/or convicted of child abuse or sexual abuse? YES NO If you are under 18, can you provide a Youth Employment Certificate? YES NO Have you been convicted of a felony within the past seven years? Please note: an affirmative response will not necessarily disqualify you for the position. Have you ever been discharged or asked to resign from any position? Have you ever been employed at or applied for a job at the JCC of Asheville, or at any other JCC? If the job requires, do you have a valid driver s license? YES NO If yes, explain YES NO If yes, explain YES NO If yes, where YES NO If no, explain

3 PLEASE READ & SIGN THE FOLLOWING: I certify that the above employment application is true and complete to the best of my knowledge. I understand that falsification of the above facts will be considered cause for the removal of my application, or will be considered reason for termination after employment begins. I acknowledge that if hired, I will be an at-will employee. I will be subject to dismissal or discipline without notice or cause, at the discretion of the employer. I also understand that this means I am free to quit my employment at any time, for any reason, without notice. I understand that the JCC conducts criminal background checks and pre-employment drug screenings on all employees prior to hire. I understand that any job offer will be contingent upon the successful completion of a criminal background check and pre-employment drug screen. Signature of Applicant Print Name For applicant s under the age of 18, a parent/guardian s signature is also required: By signing, I give permission for the above-named applicant to see employment at the Asheville JCC and understand that any off of employment will be conditioned upon a satisfactory criminal background check and drug test. I understand that the JCC will not release the results of the criminal background check and drug test to anyone without the written consent of the above-named applicant. Parent/Guardian of Applicant Printed Name **************************************************************************************************( For Office Use Only-Do Not Write Below This Line) Verification of Past Employment (if any): Verification of Professional References: Verification of Personal References: Verification of Educational Qualifications (if applicable):

4 APPLICANT INFORMATION Please print name as shown on photo Identification Card you will take to Law Enforcement Agency. Name: Last: of Birth: First: Place of Birth: Middle: Residence: Maiden Name: Aliases: Sex: Male Female Race: (Write the appropriate letter in the space provided) W -White B -Black I -American Indian A -Asian or Pacific Islander U -Unknown Employer and DOCD 319 Chapanoke Rd. Ste 120 Raleigh, NC, Reason Fingerprinted: State and Federal Check NC Day Care Provider NCGS , to Height: Social Security Number: Weight: (*Optional) Eye Color: (Write the appropriate letters in the space provided) BLK -Black GRY -Gray MAR -Maroon BLU -Blue BRO -Brown GRN -Green HAZ -Hazel PNK -Pink XXX -Unknown Your Case NO. (OCA): DOCD Type of Transaction: Non-Federal User Fee NCFP Card Type: Child Care Provider Hair Color: (Write the appropriate letters in the space provided) BAL -Bald BLK -Black BLN -Blond or strawberry BRO -Brown GRY -Gray or partially RED -Red or Auburn SDY -Sandy *Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records. This form is to be submitted to the Division of Child Development and Early Education with all other required items for a criminal history check to be conducted. Do NOT send this form to the SBI. YOUR NAME MUST MATCH ON ALL FORMS, INCLUDING FORM DHHS-004

5 ELECTRONIC FINGERPRINT SUBMISSION RELEASE OF INFORMATION I authorize the North Carolina Department of Justice through the State Bureau of Investigation, Criminal Information and Identification Section, to perform a national criminal history record check in connection with my fitness to be a child care provider/employee, or other household member of a child care program regulated by the Department of Health and Human Services, Division of Child Development and Early Education pursuant to N.C.G.S. NCGS , to I understand that the North Carolina State Bureau of Investigation, Criminal Information and Identification Section, the Federal Bureau of Investigation, and its officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I understand that the above named agency cannot provide a hard copy of the results of this criminal history record check to me. Applicant s Name DOB (Please print name clearly as it appears on your photo Identification Card you will present to Agent) Applicant s Signature Parent/Legal Guardian s Signature if applicant is under age 18 I authorize the above named subject to be fingerprinted and have the fingerprints submitted to the SBI electronically. Agency Authorized Official s Signature (or Applicant) Printed Name Number I certify that I have taken the fingerprints of the above named subject and forwarded them electronically to the SBI/Criminal Information and Identification Section. Signature of Official Taking Fingerprints Agency Seal/Certification This form is to be submitted to the Division of Child Development with all other required items for a criminal history check to be conducted. Do NOT send this form to the SBI. THE NAME ON YOUR FINGERPRINT CARD MUST MATCH WITH THE OTHER ITEMS SUBMITTED TO THE DIVISION.