Online Application for Employment

Date of Application:

Position(s) applying for:

Name:

Street:

City:

State:

Zip:

Phone Number:

Best time to be reached:

Have you ever been employed here before?:

Yes

No

Are you employed now?:

Yes

No

May we contact your present employer?:

Yes

No

On what date would you be available for work?:

Are you available to work:

Full time

Part Time

Temporary

Can you travel to workshops/training if required?:

Yes

No

Educational Background

High School Name:

Years Completed:

9

10

11

12

GED

College Name:

Years Completed:

1

2

3

4

Grad

Specialized_Training:

Describe specialized training, apprenticeships, and skills (First Aid, CPR,CDA, Early Childhood training, etc.)

Additional Info:

State any additional information you feel may be helpful to us in considering your application.

References: Give Name, Address and Telephone Number of Three References

Reference 1:

Reference_2:

Reference_3:

Employment Experience - Please attach a resume.

Please attach your resume in an e-mail to Lori Moulton at moultolj@potsdam.edu

Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, sex or national origin.

Employer:

Phone Number:

Address:

Dates Employed:

Job Title:

Supervisor:

Reason for Leaving:

Employer:

Phone Number:

Address:

Dates Employed:

Job Title:

Supervisor:

Reason for Leaving:

If you have additional previous employers, please include with your resume.

Hours you are available to work:

Students, please attach a class schedule along with your resume in an e-mail to Lori Moulton at moultolj@potsdam.edu.

Age Group Preference:

Infants (6 weeks - 12 months)

Toddler Ones (12 months - 24 months)

Toddler Two's (24 months - 36 months)

Preschool (3 years - 5 years)

School Age (5 years - 9 years)

No Preference

Medical Questions

Lifting 25 lbs.:

Yes

No

Are you able to lift at least 25 pounds on a daily basis?

Lifting Training:

Yes

No

Have you had any training in proper lifting and reaching techniques?

Running:

Yes

No

Are you able to run after a child if a situation warrants it?

Health Related Limitations:

Yes

No

Do you have any health related limitations, which would impede or inhibit your job performance in any way?

By submitting this application, I am certifying that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not intended to be a contract of employment. S.P.C.C.C., Inc. is an Equal Opportunity/Affirmative Action Employer and committed to providing opportunities for women and minorities and actively seeks these candidates.

SUNY Potsdam

Online Application for Employment