EMPLOYMENT APPLICATION FORM _ DRIVERS

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PERSONAL INFORMATION

Last Name *

First Name *

Street Address *

City *

State *

Zip Code *

Email Address *

CellPhone Number *

Alternative Phone Number *

DRIVER'S LICENSE INFORMATION

DL Number *

Issuing State *

Issued On * +

Expires On * +

Do you have a valid Commercial Driver's License? *

Do you have at least two years of driving with a CDL? *

Do you have experience in transporting K-12 students? *

Please attach a copy of your valid CDL and a copy of your DOT Physical exam documentation.

Copy of CDL (front and back)

Copy of DOT Physical Showing Expiration Date

Please list 2 references who can verify the quality of your driving abilities.

	Name	Cellphone Number	Organization	Relationship
1)	Name	Cellphone Number	Organization	Relationship
2)	Name	Cellphone Number	Organization	Relationship

EDUCATION

High School *

Year Graduated *

City *

State *

Post-Secondary (Start from the most recent.)

	School	Degree	Major	Year
1)	School	Degree	Major	Year
2)	School	Degree	Major	Year
3)	School	Degree	Major	Year

AVAILABILITY

Please check the box for the time of the day you are available to drive. *

	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm
Monday	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm
Tuesday	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm
Wednesday	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm
Thursday	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm
Friday	7:00 am - 9:00 am	4:00 pm - 6:00 pm	2:30 pm - 4:00 pm	6:15 pm - 8:15 pm

Is there anything that you want us to know about your driving availability? *

WORK AUTHORIZATION

Only US citizens and aliens with legal documents to work in the United States are eligible for employment. If you are not a US citizen, Sipnayan Math Center and Afterschool program will require a copy of your Employment Authorization Document (EAD), Permanent Resident Card (green card), or any other visa that authorizes you to work with ANY US employer.

I certify that I am legally authorized to work in the United States under the authorization chosen below. *

If you chose "other", please write the type of visa that you have.

If you are not a US citizen, please upload a copy of your EAD or greencard.

BACKGROUND CHECK

IMPORTANT! It is a 21st CCLC program requirement that all employees, service contractors and volunteers who work with the program have approved criminal background check. The center will run the following background check before hiring:

NC Sex Offender Database and National Sex Offender Database
Statewide Criminal Background Check including all states in which the employee or volunteer lives or has lived for the previous five (5) years.

Please note that individuals convicted of any kind of felony and/or any offense involving sexual or physical abuse/neglect against a child are strictly prohibited from working with the 21st CCLC Program.

Please type your initial across each statement.

	Initial
1) I authorize Sipnayan Math Center and Afterschool Program LLC to conduct an investigation of my background using the NC Sex Offender Database and the National Sex Offender Database.	Initial
2) I authorize Sipnayan Math Center and Afterschool Program LLC to conduct a national criminal background check to include all states in which I live or have lived in the past 5 years.	Initial
3) I understand that if I was found convicted of any kind of felony and/or any offense involving sexual or physical abuse/neglect against a child, I will not be eligible to work with the 21st CCLC Program run by Sipnayan Math Center and Afterschool Program LLC.	Initial
4) I understand that my social security number is necessary to run an accurate criminal background check. For the security of my personal information, I understand that this information will not be collected online. Therefore, I agree to provide my Social Security number via phone to Sipnayan's HR representative.	Initial

First Name *

Last Name *

MI *

List all other names that were used previously. Please use one box for each former name.

+-

DL State *

DL Number *

Expiration Date * +

Date of Birth * +

List ALL addresses in the last 5 years starting on the current address.

	Street	City	State	From-To (Year)
1)	Street	City	State	From-To (Year)
2)	Street	City	State	From-To (Year)
3)	Street	City	State	From-To (Year)

Applicant Signature *

clear

Thank you for completing the application. We will let you know of the next steps in the process once your application is reviewed. Thanks!