Apply for a Non-Teaching Position PERSONAL INFORMATION Position for which you are applying: * Administrative Application Preschool Volunteer Early Childhood Intern Name * First Name Last Name Middle Name * Phone * (###) ### #### Email * Social Security Number * E.g. 123-45-6789 Date of Birth * MM DD YYYY Age * Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name First Name Last Name Relationship * Phone * (###) ### #### EDUCATION High School Name * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Years Attended * Graduated * Yes No Diploma * Yes No GED * Yes No College Name * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Years Attended * Graduated * Yes No Credits * Degree * WORK EXPERIENCE (Most Recent) Employer’s Name * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Position * Date: mm/yyyy to mm/yyyy * Salary/Wage * Supervisor Name * Supervisor Number * Reason for Leaving * RELEVANT EXPERIENCE 1 * 2 3 HONORS AND DISTINCTIONS 1 2 3 BACKGROUND INFORMATION Are you, or have you ever been, listed on a sex offender registry? * Yes No Are you, or have you ever been, listed on a child or dependent adult abuse registry? * Yes No Have you ever been found guilty, accepted a guilty or Alford Plea or entered a plea of no-contest for any criminal charge? * Yes No Have you ever received a deferred judgment or in some other way had a guilty plea or conviction removed from your record? * Option 1 Option 2 If you answered “yes” to any of the above questions, provide the date, incident, specific charge, and city/state in which the incident occurred. * Type N/A if not applicable. Have you ever been asked to resign from a position, or been given the choice of resigning or being terminated from your position? * Yes No Have you ever been the subject of an investigation into wrongdoing or other formal/informal proceedings, resulting in disciplinary or criminal action? * Yes No Briefly explain any “yes” responses * Type N/A if not applicable. WORK AUTHORIZATION Are you legally eligible to work in the United States? * Yes No PROFESSIONAL RESPONSIBILITIES Are you able to perform with or without reasonable accommodation, the essential job functions required for this position? * Yes No NARRATIVE RESPONSE Why do you want to work for Blaze Academy? * What experience do you have specific to the position that you are applying for and how will you use that experience to move Blaze Academy’s vision forward? * APPLICANT’S OATH I hereby certify that all the information I provided on this Blaze Academy application is accurate and I am aware that any false information can result in my termination, as well as the pursuit of legal actions by Blaze Academy Corporation. I am also aware that the insertion of my full name and initials on this electronic form is an expression of my acceptance of this oath. Name * First Name Last Name Initials * E.g. A. B. Thank you!
