200 Dent Street
Rocky Mount, VA 24151
(540) 483-5142
An Equal Opportunity / Affirmative Action Employer Maintaining a Drug Free Workplace

Application for Employment

Position Applying For: *
Date *
Where did you see this job ad? *
Last Name: *
First Name:*
M.I.
E-mail *
Primary Phone *
Primary Phone Type: *
Alternate Phone
Street Address *
Apartment/Unit #
City *
State *
Zip *

Education

* Did you graduate high school or do you have a high school equivalency diploma?
(If No:) Highest Grade completed?
Number of years of post-high school education:
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor
Name of Institution
Location
Type of Diploma/Degree/Cert
Major/Specialty
Minor

License

License (to include drivers), certificate, or other authorization to practice a trade or profession:
Type
License Number
Expiration Date
Granted By
Type
License Number
Expiration Date
Granted By
Type
License Number
Expiration Date
Granted By

References

List names, addresses, and relationships of three persons not related to you who know your professional qualifications. (These references are not a substitute for work related references.)

Full Name *
Address *
Phone *
Relationship *
Full Name *
Address *
Phone *
Relationship *
Full Name *
Address *
Phone *
Relationship *

Experience

Starting with the most recent, describe all paid, military and applicable volunteer experience. You may list significantly different jobs within the same organization as seperate items.

Experience #1

Duties *
Reason For Leaving *

    Immediate Supervisor

Experience #2

Duties *
Reason For Leaving *

    Immediate Supervisor

Experience #3

Duties *
Reason For Leaving *

    Immediate Supervisor

Experience #4

Duties *
Reason For Leaving *

    Immediate Supervisor

Experience #5

Duties *
Reason For Leaving *

    Immediate Supervisor

Experience #6

Duties *
Reason For Leaving *

    Immediate Supervisor

Miscellaneous

* Have you ever been discharged, forced to resign, or failed to have an employment contract renewed?
Please Explain:
* Are you or a member of your immediate family currently a member of the STEP Incorporated Board of Directors or of the STEP Incorporated Head Start Policy Council ?
Please list name, relation, and their title:
* Do you have any relatives working for Step?
Please list name, relation, and their title:
* When will you be able to begin work?
Please use this space to provide additional information about your qualifications or to amplify statements made in this application:
I hereby certify that all entries given in this application are true and complete, and I agree and understand that any falsifications of information herein, regardless of time of discovery, may cause forfeiture of my part of any employment in the service of STEP Incorporated, I understand that all information on this application is subject to verification.
Applicant Signature *
Date: *