Join Our Team Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 3Position Applying For–Select Position–Head Start TeacherEarly Head Start TeacherHead Start Teachers AssistantSupport StaffOtherName *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Phone *Address *Address Line 1Address Line 2City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWill you complete the mandatory training and continuing education requirements?YesNoEducation & TrainingEducation (Check Last Grade Completed) *>12th GradeHigh School DiplomaGEDSome CollegeAssociate’s DegreeBachelor’s DegreeMaster’s DegreeLayoutName of High SchoolGraduated –Select One–YesNoGrade Point AverageAddressAddress Line 1City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateLayoutName of College or UniversityGraduated –Select One–YesNoIf no, explain:Major Course of StudyGrade Point AverageAddressAddress Line 1City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateLayoutOther (College, University, Technical, Vocational, Graduate, etc.)Graduated –Select One–YesNoIf no, explain:Major Course of StudyGrade Point Average AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateList any scholarships, academic honors, awards, certificates, or special achievements: Visual Text NextEmployment HistoryStarting with your PRESENT or MOST RECENT employer, list all employment for at least the past 3 employers in consecutive order. LayoutName of Company *AddressAddress Line 1City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStatePhone *Position *Currently Employer–Select One–YesNoEmployed From MM/YY – MM/YYReason for Leaving *Name of Supervisor *May we contact this employer?YesNoLayout (copy)Name of Company *Address Address Line 1City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStatePhone *Position *Currently Employer –Select One–YesNoEmployed From MM/YY – MM/YYReason for Leaving *Name of Supervisor *May we contact this employer? YesNoLayout (copy) (copy)Name of Company *Address Address Line 1City–Select State–AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStatePhone *Position *Currently Employer –Select One–YesNoEmployed From MM/YY – MM/YY Reason for Leaving *Name of Supervisor *May we contact this employer? YesNoReferencesLayoutName (First, Last) *Company/TitleRelationship *Phone *Layout (copy)Name (First, Last) *Company/Title Relationship *Phone *Layout (copy)Name (First, Last) *Company/Title Relationship *Phone *NextHave you been convicted of any felonies other than minor traffic violations during the past 7 years? (A criminal record or a conviction will not automatically bar employment, but will be considered only as it reasonably relates to your fitness to perform in the position which you are applying.) *YesNoIf YES, please explain: *State fully why you believe you are qualified for this position:Upload your resume * Click or drag a file to this area to upload. Affidavit I certify that all statements given by me on this application, on my resume, or other supplementary material are true and correct without omission. I understand that falsification or omission of any information required by this form is sufficient grounds for immediate disqualification of candidacy or termination of my employment by Anaconda-Deer Lodge County Head Start. I authorize the references listed above to give you any and all information concerning my previous employment and any 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 understand that should employment be extended to me; I may be subject to the satisfactory results of any job-related pre-employment background checks and examinations required by Anaconda-Deer Lodge County Head Start and my signature indicates my consent to such screenings. Checkboxes *By checking this box I certify that I have read, fully understand, and accept all terms of the above statements.LayoutSignature *Clear SignatureDate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit
