Date
MM
DD
YYYY
Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Business Phone
(###)
###
####
Position applying for:
*
Social Security Number
*
Date Available to begin working
*
MM
DD
YYYY
Would you work part-time?
*
Yes
No
Name of church you attend
Number of years attended there
*
List any skills, talents or experience you have acquired and would like to use at Four Corners Home for Children:
Are you legally eligible for employment in the United States?
*
Yes
No
Have you been convicted of a crime (other than a misdemeanor) in the past 10 years?
*
Yes
No
If Yes, Please Describe:
If you are applying for a position where you will be working with children or living on Ministry grounds, Four Corners Home for Children is required to submit your fingerprints to the Department of Safety in Santa Fe, NM. Do you give your permission to be finger printed?
Yes
No
Do you have any physical condition that would affect your ability to perform duties relating to the position you have applied for?
Yes
No
If Yes, how can we accommodate you?
Would you agree to abstain from the use of alcohol and tobacco while on Ministry grounds or representing Four Corners Home for Children off grounds?
*
Yes
No
If you are applying for the houseparent position, will you agree to serve for a minimum of one year in this work if given a call to come?
Yes
No
Have you carefully read the Bi-Laws of Four Corners Home for Children, Inc. and do you understand the general working of the corporation?
*
Yes
No
Do you feel called of God to serve Him in your area on behalf of the Navajo people, in affiliation with Four Corners Home for Children?
*
Yes
No
Name of Graduate School
School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Course of Study
Number of years completed
Did you graduate?
Yes
No
Degree or Diploma (if any)
Name of College
College Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Course of Study
Number of years completed
Did you graduate?
Yes
No
Degree or Diploma (if any)
Name of Trade School
Trade School Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Course of Study
Number of years completed
Did you graduate?
Yes
No
Degree, Diploma or Certificate (if any)
Name of High School
Address of High School
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Number of years completed
Did you graduate?
Yes
No
Have you served in the U.S. Armed Forces?
Yes
No
If yes, what branch?
Describe any military training you have received that is relevant to the position for which you are applying?
Company Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Dates of Employment
Weekly Pay at the beginning of employment
Weekly pay at the end of employment
Supervisor
Reason for leaving
Job title & responsibilities
May we contact this employer?
If no, please provide a reason below
Company Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Dates of employment
Weekly pay at the beginning of employment
Weekly pay at the end of employment
Supervisor
Reason for leaving
Job title & responsibilities
May we contact this employer
If no, please provide a reason below
Company Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Dates of employment
Weekly pay at the beginning of employment
Weekly pay at the end of employment
Supervisor
Reason for leaving
Job title & responsibilities
May we contact this employer?
If no, please provide a reason below
Name of employer
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Dates of employment
Weekly pay at the beginning of employment
Weekly pay at the end of employment
Supervisor
Reason for leaving
Job title & responsiblities
May we contact this employer?
If no, please provide a reason below
Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Relationship
