MBCH Application for Employment

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip
E-Mail
Social Security Number

Are you at least 18 years of age? Yes No

If hired, can you furnish proof of age? Yes No

If hired, can you furnish proof that you are legally entitled to work in the U.S.? Yes No

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Someone who will always be able to reach you (below)

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip

________________________________________________________________________________________________

Are you related to anyone now associated or formerly associated with Missouri Baptist Children's Home? Yes No

Name of Relative (if yes)

First Name
Last Name

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Church
Member Attend
How Long?
Pastor's Name? First
Last
Pastor's/Church Phone #
Church Address Line 1
Address Line 2
City
State
Zip

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Position Preferred
Location Preferred
Who referred you to our agency?

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Present Employer
May we inquire of your present employer? Yes No
Has your application for bond ever been rejected? Yes No
If yes, state details
Have you ever been dismissed or asked to resign from a job? Yes No
If yes, state details

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Have you ever been convicted of a felony or any crime involving dishonesty, violence, illegal substances, or child abuse? Yes No
If yes, state details
Have you had a "Probable Cause" or "Reason to Suspect" finding for child abuse or neglect from a local or state child welfare agency? Yes No
If yes, state details

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Are you licensed to drive a car? Yes No
Driver License #
State
Class (type) of License Operator Chauffeur Other

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Educational Background

Elementary School

Name
Address Line 1
Address Line 2
City
State
Zip
Course of Study

Dates Attended

From to
Graduation Date

High School

Name
Address Line 1
Address Line 2
City
State
Zip
Course of Study

Dates Attended

From to
Graduation Date

College

Name
Address Line 1
Address Line 2
City
State
Zip
Major
Degree

Dates Attended

From to
Graduation Date

Graduate, Business or Other School

Name
Address Line 1
Address Line 2
City
State
Zip
Course of Study
Degree

Dates Attended

From to
Graduation Date

________________________________________________________________________________________________

Employment Experience - Start with your present or last job. Include any job-related military service assignments and volunteer activities. Complete addresses must be provided to process application.

Employer
Address Line 1
Address Line 2
City
State
Zip
Phone #
Job Title
Supervisor
Reason for Leaving

Dates Employed

From to
Work Performed	Part-Time Full-Time
Hourly Rate/Salary Starting Final

Employer
Address Line 1
Address Line 2
City
State
Zip
Phone #
Job Title
Supervisor
Reason for Leaving

Dates Employed

From to
Work Performed	Part-Time Full-Time
Hourly Rate/Salary Starting Final

Employer
Address Line 1
Address Line 2
City
State
Zip
Phone #
Job Title
Supervisor
Reason for Leaving

Dates Employed

From to
Work Performed	Part-Time Full-Time
Hourly Rate/Salary Starting Final

Employer
Address Line 1
Address Line 2
City
State
Zip
Phone #
Job Title
Supervisor
Reason for Leaving

Dates Employed

From to
Work Performed	Part-Time Full-Time
Hourly Rate/Salary Starting Final

________________________________________________________________________________________________

Military Service:

Dates to
Branch or Service
Rank or Grade
Type of Discharge

________________________________________________________________________________________________

References (Do not list relatives or previous employers. All addresses must be complete)

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip
How Know?

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip
How Know?

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip
How Know?

First Name
Last Name
Phone #
Address Line 1
Address Line 2
City
State
Zip
How Know?

________________________________________________________________________________________________

Additional Information

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© MBCH 2002 * Last Modified 3/12/2008 * Webmaster