Job Application Form Job Application Form Applicant's Name Applicant's Email Step 1: Type of Employment Please tell us your desired student level---Infant / ToddlerPreschoolBoth Please tell us your desired employment levelFull-TimePart-TimeSubstituteAny Next Step 2: Personal History Statement Full Name Social Security No.* Texas Driver's License No.* *Please indicate if you do not have a Social Security number or a Texas driver’s license. Home Telephone No. (A/C) Date of Birth Mailing Address 2-1: Education Elementary or High School (check highest year completed)123456789101112 Did you graduate or receive a GED?YesNo Schools Attended Describe any other special training you have had which you feel is pertinent. Including Continuing Education Units. Give dates, locations, and the name of the organization or agency sponsoring the training. List any professional licenses, certifications, or credentials you hold. 2-2: Employment and Experience Show all positions held within the last 10 years beginning with current or last employer. Full-TimePart-Time Full-TimePart-Time Full-TimePart-Time Full-TimePart-Time A. Describe the duties of each position listed above that were in the areas of child-care services, child-care personnel supervision, skill-based instruction, recreational or youth development program, and program management or administration. B. Describe any other experience you have had which you feel is pertinent. Include volunteer work in the description. Give dates and locations. 2-3: Previous Licenses/Registrations/Listings A. Has the Texas Department of Family and Protective Services or any other agency ever registered or listed you to care for children?YesNo If “Yes,” when were you registered or listed? Address registered If you were registered under another name, what was the name? B. Has the Texas Department of Family and Protective Services or any other agency ever licensed you to care for children?YesNo If “Yes,” what kind of license did you have? When were you licensed? Name of operation Operation address C. Are you now a foster parent?YesNo D. Have you ever been denied a permit to care for children?YesNo If “Yes,” when were you denied? For what type of child care were you denied? Operation's address What was the reason for the denial? E. Have you ever had a child-care permit revoked or have you ever been barred/prohibited from operating?YesNo If “Yes,” when did the revocation or bar occur? What was the reason for the revocation or bar? Operation's address If the revocation or bar occurred in another state, list the name and address of the regulatory body that issued the revocation or bar Indicate the type of child care permit that was revoked or the type of child care you were barred from operating? F. Has an operation that you owned or operated ever been placed on probation?YesNo If “Yes,” when was it placed on probation? What was the reason it was placed on probation? Operation's address 2-4: People in the Home For Child Care Operations in Homes Only (Complete only if child care will be provided in the home where the caregiver and family reside.)The following people 14 years old or older live in my home in addition to myself. 2-5: Health A. Are you physically and/or emotionally fit to act as the director/administrator of a child care operation?YesNo If “No,” please explain. B. Is any person listed in Section 2-4 physically and/or emotionally impaired?YesNo If “Yes,” please explain. 2-6: Child Abuse/Neglect Have you or has any person listed in Section 2-4 ever been investigated for abusing or neglecting a child by any of the following agencies? A. Child Protective Services of the Texas Department of Family and Protective ServicesYesNo B. County child welfare agencyYesNo C. Law enforcement agency (police, sheriff, etc.)YesNo D. Child welfare agency in another stateYesNo E. Other (specify)YesNo If “Yes” to any of the above: What was the child’s name? How was the child related? When did this occur? Where? 2-7: Criminal Charges/Convictions A. Have you or has any person listed in Section 2-4 ever been convicted of a felony or misdemeanor?YesNo If “Yes,” give name of person(s) Date of Conviction Location Give details including type of conviction and disposition B. Do you or does any person listed in Section 2-4 have felony or misdemeanor charges pending with the county or district attorney or is anyone now complying with the terms of a deferred adjudication?YesNo If “Yes,” give name of person(s) Type of Charge County where charges are pending or length of deferred sentence. Court No. Location Give details I certify that this information contains no willful misrepresentation or falsification and that it is true and complete to the best of my knowledge and belief. I hereby authorize Austin Play Garden to contact the persons listed on this form. I understand that Austin Play Garden may contact others and, at any time, seek verification of any and all information on this form. I understand that any willful misrepresentation is cause for immediate denial of the application or later revocation of the license. Signature Date BackNext Step 3: Affidavit for Employment Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home AN APPLICANT FOR TEMPORARY OR PERMANENT EMPLOYMENT with a licensed child-care facility, licensed child-placing agency or registered child-care home whose employment or potential employment with the facility, agency, or home involves direct interaction with or the opportunity to interact and associate with children must execute and submit the following affidavit with the application for employment: STATE OF COUNTY OF I swear or affirm under penalty of perjury that I do not now and I have not at any time, either as an adult or as a juvenile: Been convicted of; Pleaded guilty to (whether or not resulting in a conviction); Pleaded nolo contendere or no contest to; Admitted; Had any judgment or order rendered against me (whether by default or otherwise); Entered into any settlement of an action or claim of; Had any license, certification, employment, or volunteer position suspended, revoked, terminated, or adversely affected because of; Resigned under threat of termination of employment or volunteerism for; Had a report of child abuse or neglect made and substantiated against me for; or Have any pending criminal charges against me in this or any other jurisdiction for; Any conduct, matter, or thing (irrespective of formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction): Any felony; Rape or other sexual assault; Physical, sexual, emotional abuse and/or neglect of a minor; Incest; Exploitation, including sexual, of a minor; Sexual misconduct with a minor; Molestation of a child; Lewdness or indecent exposure; Lewd and lascivious behavior; Obscene or pornographic literature, photographs, or videos; Assault, battery, or any violent offense involving a minor; Endangerment of a child; Any misdemeanor or other offense classification involving a minor or to which a minor was a witness; Unfitness as a parent or custodian; Removing children from a state or concealing children in violation of a court order; Restrictions or limitations on contact or visitation with children or minors resulting from a court order protecting a child or minor from abuse, neglect, or exploitation; or, Any type of child abduction. Except the following (list all incidents, locations, description, and date)(if none, write NONE) I certify that this information contains no willful misrepresentation or falsification and that it is true and complete to the best of my knowledge and belief. I hereby authorize Austin Play Garden to contact the persons listed on this form. I understand that Austin Play Garden may contact others and, at any time, seek verification of any and all information on this form. I understand that any willful misrepresentation is cause for immediate denial of the application or later revocation of the license. Signature Date BackNext Step 4: Upload Your Resume Please attach your resume here. (we accept files in DOC or PDF format) Back