Date

Last Name

First Name

Middle Name

Other names by which you have been known (Maiden, etc.)

Social Security Number

Home Phone

Business Phone

Cell Phone

Email Address

Current Address

City

State

Zip Code

Have you lived at your current address at least 5 years?

Yes No

Previous Address

City

State

Zip Code

May we contact you at work?

Yes No

Driver's License Number

Issuing State

Can you presently provide proof of authorization to work in the U.S. as required by the Immigration Reform Act of 1986?

Yes No

Have you ever applied for a job with LCYDC?

Yes No

When and for which position(s)?

Have you ever been employed or contracted by LCYDC?

Yes No

Please list the position(s) and dates of employment:

Do you have any relatives who are employed by LCYDC?

Yes No

Please list their names and your relationship to them:

Position Desired

Hours Desired

FullTime PartTime Intern Practicum Volunteer

How did you learn of this position?

Newspaper Internet Friend Other

Please tell us how you learned of this position:

Date Available to start

Salary Requirements

What hours shift are you available to work? (Check all that apply)

1st Shift 2nd Shift 3rd Shift Other

Please tell us other availability:

IMPORTANT: In answering the following questions, include offenses or charges to which a guilty or nolo contendere plea was entered or, if convicted, a sentence if probation was imposed. The fact that you are awaiting trail and/or have a record of conviction will not necessarily bar you from employment, but will be considered in the context of the entire application and position applied for. Failure to answer or answer truthfully shall invalidate employment consideration.

Must be at least 21 for employment consideration.

Have you ever been convicted in any court, whether civilian or military, of a violation of the law?

Yes No

Are you now facing charges and/or awaiting trial for a violation of the law other than traffic violations?

Yes No

Have you ever been the subject of a Child Abuse/Neglect investigation which was determined to be "indicated"?

Yes No

Have you been convicted of Reckless Driving, DWI/DUI, or had an accident in the past 3 years?

Yes No

If you are not sure if you have had violations within the past 3 years, please note so at the bottom of this section, rather than responding "No". Ability to be insured by LCYDC insurance carrier is a requirement for most positions.

Are you presently using illegal drugs?
(LCYDC is a drug-free workplace. Random drug screens are performed monthly)

Yes No

If you answered "Yes" to any of the above questions, please explain.

Please list all employment within the past 10 years, starting with most recent. Please include temporary & volunteer work.

May we contact your present employer?

Yes No

Employer

Employer Name

Street

City

State

Zip

Nature of Work

Reason for Leaving

Salary

From Date

To Date

Supervisor

Phone Number

1

Add More Employment Experience

Branch of Service

Dates Served

Grade/Rank at Discharge

Occupational Specialization

Special training & relevant skills acquired

Include all periods of schooling beginning with High School:

Education History

High School, Technical School, Colleges, & Other Schools

Years Completed

Degree Earned

Field or Major

Grade Point Average

1

Add More Education History

Please list school, professional, and/or community service. (If you wish, you may omit any organization or activity, the name of which indicates race, sex, color, religion, or national origin of its members.)

School, Professional and/or Community Service

Name of Activity or Organization

Position or Role

Accomplishments and/or Duties

From Date

To Date

1

Add More Organizations

List any Professional or Occupational Licenses held including the license number and expiration date.

List any special training, skills, or experience you would like considered, relative to the position for which you are applying.

List three people (one professional, two personal) who aren’t already mentioned in the Employment section whom you have known for at least two years.

Professional Affilation: Reference 1

Name

Complete Address

Email Address

Occupational Relationship

Years Known

Personal Affilation: Reference 2

Name

Complete Address

Email Address

Personal Relationship

Years Known

Personal Affilation: Reference 3

Name

Complete Address

Email Address

Personal Relationship

Years Known

An Equal Opportunity Employer: Discrimination against any individual because of race, sex, color, religion, national origin, age, ethnicity, disability status, or status as a veteran or disabled veteran, is prohibited. The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals at least 40 years of age. If you believe you have been discriminated against, you may notify the Equal Employment Opportunity Commission, the Federal Communications Commission, the Office of Federal Contract Compliance Programs or other appropriate federal or state agencies.

Please read carefully. As an applicant, you agree to and understand the following:

You must satisfy the requirements of our post-offer drug screening process.
You must satisfy the requirements of our post-offer evaluation process.
You must execute and agree to abide by the agency’s Arbitration Agreement.
You must provide proof of identity and authorization to work in the U. S. as required by the Immigration Reform and Control Act of 1986.
You will be required to meet the minimum age requirements of applicable laws.
I understand that nothing in this employment application, or in LCYDC’s personnel guidelines, handbooks, policies or procedures is intended to create, or does create, any employment contract between the Center and me. I understand that if I am hired by LCYDC, my employment shall be at-will and I may resign or be terminated at any time for any reason.
If you have signed an employment agreement, confidentiality agreement or any other document with a prior employer that might restrict your activities if hired by LCYDC, you must disclose this fact before a job offer is made. Failure to disclose such information may lead to termination of your employment.
I understand and agree that if hired by LCYDC, my employment may be terminated if subsequent to my hiring, the Youth Development Center becomes aware that I have falsified or misled the Center regarding any information provided on this application or during the application process.
I understand and agree that my agreement to arbitrate any employment dispute pursuant to the provisions of the Lee County Youth Development Center’s Dispute Resolution Program, including but not limited to claims related to my application for employment, and my signature to the Arbitration Agreement provided by LCYDC is a requirement for consideration for employment with LCYDC. I understand that LCYDC will not consider my application unless and until it receives the signed Arbitration Agreement.

Signature

Date (enter 4/23/2024)

Submit Application

Personal Data

Work Preference

Additional Information

Employment Experience

Employer

Military Experience

Education

Education History

Activities, Licenses, & Special Skills

School, Professional and/or Community Service

References

Professional Affilation: Reference 1

Personal Affilation: Reference 2

Personal Affilation: Reference 3

Disclosure

Signature