775 Hazen St., Paw Paw, MI 49079
269-657-2581 | 800-792-0366
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About Us
Board of Directors
Cultural Competency
Employment
Indiana Tech Partnership!
Policy Council
TCHS Committees
What We Offer
Center Based
Classroom Areas
Conscious Discipline
Disability Services
Dual Language Services
Early Head Start Services
Education Services
Expectant Families Services
Family Services
Father/Male Involvement Initiative
Health Services
Home Based
School Readiness
What Children Learn
How to Enroll
Resources
Locations Under Construction
Contribute
Community Partners
Employment
Internships
Contribute
News
Donate!
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Online Application
Personal Information
To the Applicant: We appreciate your interest in our organization and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in seeking to place you in a position which, in our judgment, best meets your qualifications. We are an equal opportunity employer and will not unlawfully discriminate on the basis of race, color, sex, religion, national origin, age, marital or veteran status, genetic information, the presence of a medical condition or disability, height, weight, or any other protected status.
Full Name
*
Maiden Name
Home Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
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New Jersey
New Mexico
New York
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Have you resided outside of the State of Michigan as an adult within the 10 years immediately preceding the date of this application?
Yes
No
List the States
Cell Phone
Home Phone
*
Email
*
How did you hear about employment with Tri-County Head Start?
Are you authorized to work in the U.S.?
Yes
No
Have you been previously employed here?
Yes
No
If yes, dates and supervisor name(s)
Have you filed an application here before?
Yes
No
If yes, dates
List any friends working here
List any relatives working here
Have you ever had a child in Head Start?
Yes
No
If yes, when and where?
Employment
Position(s) applied for
*
Date available to work
Kind of work sought
What special training, skills, qualifications or other experiences do you have that relate to the position(s) applied for?
Training, skills & qualifications
What language(s) do you speak fluently?
Bus Drivers
Location(s) applied for
Do you have a CDL with a PS endorsement?
Yes
No
For each unexpired commercial motor vehicle operator’s license or permit held, record the following:
Issuing State
License #
Expiration Date
Issuing State
License #
Expiration Date
Issuing State
License #
Expiration Date
List and include facts and circumstances of all motor vehicle accidents you were involved in for the past 3 years
List all violations of motor vehicle laws or ordinances you forfeited bond or were convicted of in the past 3 years
Give a detailed statement of facts and circumstances of any suspension, denial, or revocation of any license, permit, or privilege to operate a motor vehicle that has been issued to you
Employment Experience
Employment 1
Employer
Address
City
State
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
Phone
Job Title
Supervisor
Reason for Leaving
Date Started
Date Ended
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary
Work Performed
Employment 2
Employer
Address
City
State
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
Phone
Job Title
Supervisor
Reason for Leaving
Date Started
Date Ended
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary
Work Performed
Employment 3
Employer
Address
City 3
State
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
Phone
Job Title
Supervisor
Reason for Leaving
Date Started
Date Ended
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary
Work Performed
Employment 4
Employer
Address
City
State
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
Phone
Job Title
Supervisor
Reason for Leaving
Date Started
Date Ended
Starting Hourly Rate/Salary
Ending Hourly Rate/Salary
Work Performed
Education
High School
Diploma
Yes
No
Number of Years
Courses of Study
College
Degree
Yes
No
Number of Years
Courses of Study
Graduate School
Degree
Yes
No
Number of Years
Courses of Study
GED
Diploma
Yes
No
Number of Years
Courses of Study
Vocational/Training
Diploma
Yes
No
Number of Years
Courses of Study
References
REFERENCES WILL BE CONTACTED: List at least three professional references, current within the last three years. A minimum of one former supervisor must be included.
Name
Business
Phone
Address
City
State
State
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
Name
Business
Phone
Address
City
State
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
Name
Business
Phone
Address
City
State
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
Name
Business
Phone
Address
City
State
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
Military Service Record
If yes, what branch?
Rank at discharge
Date of discharge
Are you in the reserves?
Yes
No
If yes, date obligation ends
Special/Technical Training
Additional Information
More Information
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Address
Emergency Contact City
Emergency Contact State
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
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APPLICANT’S CERTIFICATION AND AGREEMENT
PLEASE READ CAREFULLY
Certification of Truthfulness.
I certify that all statements on this Application for Employment are made truthfully and without evasion, and further understand and agree that such statements may be investigated and if found to be false will be sufficient reason for not being employed, or if employed may result in my dismissal.
Authorization for Employment/Educational Information.
I authorize the references listed in the Application for Employment, and any prior employer, educational institution, or any other persons or organizations to give Tri-County Head Start any and all information concerning my previous employment/educational accomplishments, disciplinary information or any other pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I hereby waive written notice that employment information is being provided by any person or organization.
Employment at Will.
If I am hired, in consideration of my employment, I agree to abide by the rules and policies of Tri-County Head Start, including any change made from time to time, and agree that my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either Tri-County Head Start or myself. I understand that no administrator or other representative of Tri-County Head Start, other than the Director, has any authority to enter into any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. Any such agreement made by the Director must be made in writing to be effective.
Authorization to Work.
If I am selected for hire, I will be offered employment provided I verify that I am authorized to work as requested by the Immigration Reform and Control Act of 1986.
Need for Accommodation.
If I am disabled and require an accommodation to perform the job, I must notify Tri-County Head Start of that need within 182 days after I knew or reasonably should have known that an accommodation was needed. Failure to do so will bar me from alleging that Tri-County Head Start has not accommodated me as required by law.
Criminal Records Check.
I authorize Tri-County Head Start to conduct a criminal history and sex offender registry check from the Michigan State Police and from any other appropriate law enforcement agency. If necessary, I will provide a set of fingerprints to the necessary authority for the purposes of conducting a criminal history check. I understand that the information obtained through a criminal history check will be used by Tri-County Head Start to determine whether I may be employed by Tri-County Head Start. Child Care Licensing Regulations and Head Start Performance Standards are used in the determination. I agree that I will not make any claims or allegations against Tri-County Head Start or its personnel on account of the criminal history check, and I expressly waive and release any such claim or allegation.
Release of Medical Information.
I authorize every medical doctor, physician or other healthcare provider to provide any and all information, including but not limited to, all medical reports, laboratory reports, X-rays or clinical abstracts relating to my previous health history or employment in connection with any examination, consultation, test or evaluation as may be required by Tri-County Head Start. I hereby release every medical doctor, healthcare personnel and every other person, firm, officer, corporation, association, organization or institute which shall comply with the authorization or request made in this respect from any and all liability. I understand that this release will not be sent to my physician or other healthcare provider until a job offer has been made.
Driving Records Check.
I authorize Tri-County Head Start and its agents the authority to make investigations and inquiries of my driving record.
Limitation on Claims.
I agree that any lawsuit against Tri-County Head Start and/or its governing authority, board of directors, employees and agents arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within the following time limits or be forever barred: (a) for lawsuits requiring a Notice of Right to Sue from the EEOC, within 90 days after the EEOC issues that Notice; or (b) for all other lawsuits, within (i) 180 days of the event(s) giving rise to the claim, or (ii) the time limit specified by statute, whichever is shorter. I waive any statute of limitations that exceeds this time limit.
Fringe Benefits.
I understand that it is my responsibility to provide documentation for verification of eligibility for fringe benefits as well as information regarding mailing address, telephone numbers or contact arrangements, withholding exemptions and dependent information. Tri-County Head Start shall rely on the most recent information for all purposes.
Confidentiality.
If I am hired, I agree that during my employment all records, papers, information and documents to which I may have access in the course of employment are considered confidential by Tri-County Head Start and will be treated as such by me and Tri-County Head Start.
Physical Exam and Drug Testing.
I agree to take a physical exam following an offer of employment. I agree to drug and alcohol testing at the employer’s request including the withdrawal of specimen(s) of my blood, urine or hair for chemical analysis. One purpose of this analysis is to determine or exclude the presence of alcohol, drugs or other substances. Tri-County Head Start has a Zero Tolerance Policy for Drugs and Alcohol and I understand that decisions concerning my employment will be made as a result of this test.
Right to Inspect.
I agree that the contents of my offices, work spaces, desks, computer and computer-generated data, any of Tri-County Head Start’s property that I may be using, and any of my own property, including but not limited to vehicles, that I bring onto Tri-County Head Start’s premises may be inspected by Tri-County Head Start at any time.
Credit Report.
I understand that Tri-County Head Start may request a consumer report or an investigative consumer report, including information as to my character, general reputation, personal characteristics and mode of living for the general purpose of evaluating my application for employment. I further understand that I may request in writing from Tri-County Head Start a complete and accurate disclosure of the nature and scope of the investigation requested. I consent to the furnishing of such report to Tri-County Head Start.
Consideration of Employment.
I agree to the above terms of employment if I am employed by Tri-County Head Start. Should I be employed, I understand and agree that these provisions of my employment can be revised only by a signed contract authorized by a written resolution as described above. I understand and agree that, except as provided above, all compensation, benefits, programs, rules and policies of Tri-County Head Start are subject to exception or change at any time as decided by Tri-County Head Start in its sole discretion.
Sign here to acknowledge you understand items 1-15 above
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