EMPLOYMENT APPLICATION

(This type of application should be completed by all who seek any position that will involve the supervision and/or custody of
children or youth. You should tailor the application to the specific circumstances in your congregation. However, the employment
application should include sections for personal identification, job qualifications, experience and background for the past
5-10 years, references, a criminal history, and a waiver/consent to a periodic criminal records check or fingerprinting.)

APPLICANT INFORMATION
Name (Last) (First) (Middle) Date

Address City State ZIP Code

Telephone Alternate Telephone Best Contact Time E-Mail Address

Social Security Number Driver's License No./Issuing State Date of Birth

Position Apply For Type of Work Desired

When Are You Available to Begin Work? Will You Work Overtime?
Yes No

If hired, can you provide evidence that you are authorized and of legal age to work in the United States?
Yes No

In Case of Emergency Notify Telephone Name of Nearest Relative Telephone

EDUCATION
SCHOOL NO. YEARS
TYPE NAME/LOCATION COURSE OF STUDY ATTENDED DEGREE/DIPLOMA

HIGH SCHOOL

BUSINESS/TECHNICAL

COLLEGE

GRADUATE

OTHER

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Professional Organizations:

First-Aid Training? Date Completed

CPR Training? Date Completed

EMPLOYERS
(List all jobs and contracts held by you during the past five continuous years)

CURRENT EMPLOYER
Company Name Telephone

Address City State ZIP Code

Position Held From To Starting/Ending Salary

Reason for Leaving Supervisor

PREVIOUS EMPLOYER
Company Name Telephone

Address City State ZIP Code

Position Held From To Starting/Ending Salary

Reason for Leaving Supervisor

PREVIOUS EMPLOYER
Company Name Telephone

Address City State ZIP Code

Position Held From To Starting/Ending Salary

Reason for Leaving Supervisor

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PREVIOUS EMPLOYER
Company Name Telephone

Address City State ZIP Code

Position Held From To Starting/Ending Salary

Reason for Leaving Supervisor

PREVIOUS EMPLOYER
Company Name Telephone

Address City State ZIP Code

Position Held From To Starting/Ending Salary

Reason for Leaving Supervisor

MILITARY STATUS
Have You Served in the U.S. Armed Services? Branch Start Date End Date

Yes No

Rank/Rate at Discharge Type of Service Type of Discharge

Special Training/Experience Received in the U.S. Armed Services Draft Status Reserve Status

CRIMINAL HISTORY
Have you ever been convicted of a criminal offense?
Check One: Yes No

Do you currently have any criminal actions pending in which you are the Defendant? (Not Applicable to California Applicants)
Check One: Yes No

Are you currently on probation or parole?

If you answered "Yes" to any of the above questions, please explain the nature of the offense and provide the date of the offense
and the county and state in which it occurred.

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PERSONAL REFERENCES:
Name Address Phone Occupation Relationship

Name Address Phone Occupation Relationship

Name Address Phone Occupation Relationship

APPLICANT STATEMENT

(Read and Sign Below)

I certify that this employment application was completed by me and that all of the information on this
application is true and correct to the best of my knowledge. I understand that any falsification, misrepresentation, or
omission of facts called for herein will result in my disqualification from further consideration or dismissal from
employment if I am hired. I have reviewed the Authorization for Criminal Records Verification and Fingerprint
Information and acknowledge that I understand the terms set forth therein. I understand that this employment
application is not valid without my signature.

Print Name

Signature Date

CHURCH MUTUAL INSURANCE COMPANY AND HERMES SARGENT BATES WISH TO POINT OUT THAT NO WARRANTY ATTACHES TO
THESE DOCUMENTS, AND IN FACT , THESE DOCUMENTS MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR ENTITY.
THESE DOCUMENTS ARE NOT A SUBSTITUTE FOR GOOD PRACTICE , PROPER SUPERVISION, AND DILIGENT OVERSIGHT AND CONTROL .
THERE IS NO GUARANTEE THAT THESE DOCUMENTS WILL PROTECT ANY FACILITY THAT CHOOSES TO USE THEM . BEFORE USING
THESE DOCUMENTS OR ANY SIMILAR DOCUMENTS, YOU SHOULD CONSULT WITH YOUR OWN ATTORNEY TO MAKE CERTAIN THAT THE
DOCUMENT YOU EVENTUALLY USE IS CORRECT AND CURRENT UNDER THE LAW OF YOUR PARTICULAR JURISDICTION AND THAT THE
DOCUMENT MEETS YOUR NEEDS FOR YOUR PARTICULAR SITUATION.

FM:S868 (8-2008) HSB -4-