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Have you lived in Pennsylvania state for the past 5 years?
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Current Head Start Parent?
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Previous Head Start Parent?
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Bi-lingual Language
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Position Desired
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Date Available to Start
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MM slash DD slash YYYY
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Reason for Leaving Job
Company name
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Position Type of Work
Reason for Leaving Job
Company name
Dates Employed
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Position Type of Work
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Armed Forces Americas
Armed Forces Europe
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State
Phone
Years Known
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American Samoa
Arizona
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California
Colorado
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District of Columbia
Florida
Georgia
Guam
Hawaii
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Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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North Carolina
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Northern Mariana Islands
Ohio
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Utah
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Vermont
Virginia
Washington
West Virginia
Wisconsin
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State
Phone
Years Known
Consent
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I understand that if I am selected for the position for which I am applying, I will be an employee at-will, and that, if I am employed, both the Company and I remain free to terminate our relationship at any time and for any reason. I further understand that no representative of the Company has the authority to make any agreement to the contrary, acknowledge that no contrary statements, representations, or promises have been made to me, and am aware that such Company documents as employee handbooks, personnel policies, and the like, do not constitute contracts of employment between me and the Company.
I certify that the information contained in this application is true and I understand that if any of it is found to be false, my application may be rejected or I may be discharged from employment. I grant the Company permission to investigate my personal, educational, and employment history and to contact persons, organizations, institutions, or government agencies who may have knowledge of me.
I acknowledge that I have the right of appeal in the decision of job hiring by writing to the Executive Director who will inform the Policy Council at Monroe County Head Start, 212 West Fourth Street, E Stroudsburg PA 18301.
I have read and understand the above.
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Applicant's Declaration
Have you received Act 33 clearance? (Child line/DPW and State Police or FBI clearance)
*
Yes
No
Date received
MM slash DD slash YYYY
Attach records
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Have you ever been convicted of, or adjudicated delinquent for, any of the following crimes: sexual abuse, sexual assault, sexual exploitation or child pornography, incest, rape, murder, kidnapping, contributing to the delinquency of a minor, felonies involving controlled substances, violent felonies, child abuse or other crimes against children?
*
Yes
No
If Yes, explain
Are you currently under investigation by a law enforcement or social service agency for child abuse, neglect or assault on a child?
*
Yes
No
If Yes, explain
Has a finding of confirmed (or suspected) child abuse or neglect ever been made against you by a social services agency as a result of an investigation into alleged acts of child abuse committed by you?
*
Yes
No
If Yes, explain
My name has been the same for the last five years
*
Yes
No
If No, identify former names in the last five years
Consent
*
I acknowledge that all information submitted above are true.
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