Application Instructions General Application for Employment To apply for this position, you must currently be a resident of the United States and legally allowed to work here.Are you currently a US Resident? Yes Last Name First Name MI Maiden Name (If Applicable) Social Security Number Present Address Street Number City State Zip Code Home PhoneCell PhoneWork PhoneEmergency PhoneHave You Ever Worked for Us Before? Yes No Are You at Least Age 18? Yes No Do You Have the Right to Work in the Us? Yes No Date of Birth MM slash DD slash YYYY Are You Employed Now? Yes No Why Do You Desire a Change? Please Circle Gender Male Female Email Position Applied for? How Soon Can You Report for Work? Type FT PT Temp Days You Can Work M T W Th F Sa Su Shifts you can work 1st 2nd 3rd Indicate What Current Certifications / Training You Possess (Check) CPR 1st Aid CPI Med Admin Other List Below List All Other Training You Have Pertinent to This Position Have You Ever Been Dismissed/ Asked to Resign From Employment? Yes No Have You Ever Been Dismissed/ Asked to Resign From Employment? Yes No If Yes, Explain Did any dismissal or requested resignation involve abuse, neglect or any act of aggression? Yes No If Yes, Explain Have You Ever Been Convicted of a Felony? Yes No Have You Ever Been Convicted of a Misdemeanor? Yes No If Yes, State Conviction, Date, Court and Place Where Offence Occurred. Have You Ever Been Required to Register as a Sexual Offender? Yes No If Yes, Explain Do You Have a Valid Driver’s License? Yes No DL Number Dl Issued in What State Type of Auto Insurance Liability Only Full Coverage Number of Traffic Violations Within the Past 5 Years? EDUCATIONHigh School City/State Did You Graduate Yes No Year College/university City/state Degree Earned Year EMPLOYMENT HISTORY (Start with present employer and continue for a 5 year history – ask for additional sheets if necessary)1) Name of Employer Address of Employer Phone NumberImmediate Supervisor & Position Date Hired MM slash DD slash YYYY Starting Pay Your Job Title Date Left MM slash DD slash YYYY Final Pay Job Duties Reason for Leaving May We Use This Employer as a Reference? Yes No 2) Name of Employer Address of Employer Phone NumberImmediate Supervisor & Position Date Hired MM slash DD slash YYYY Starting Pay Your Job Title Date Left MM slash DD slash YYYY Final Pay Job Duties Reason for Leaving May We Use This Employer as a Reference? Yes No 3) Name of Employer Address of Employer Phone NumberImmediate Supervisor & Position Date Hired MM slash DD slash YYYY Starting Pay Your Job Title Date Left MM slash DD slash YYYY Final Pay Job Duties Reason for Leaving May We Use This Employer as a Reference? Yes No 4) Name of Employer Address of Employer Phone NumberImmediate Supervisor & Position Date Hired MM slash DD slash YYYY Starting Pay Your Job Title Date Left MM slash DD slash YYYY Final Pay Job Duties Reason for Leaving May We Use This Employer as a Reference? Yes No 5) Name of Employer Address of Employer Phone NumberImmediate Supervisor & Position Date Hired MM slash DD slash YYYY Starting Pay Your Job Title Date Left MM slash DD slash YYYY Final Pay Job Duties Reason for Leaving May We Use This Employer as a Reference? Yes No Foster Parent Application To apply for this position, you must currently be a resident of the United States and legally allowed to work here.Are you currently a US Resident? Yes Applicant/Payee Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Middle Last Primary Language Secondary Language Work/Cell Telephone NumberE-mail Address(Required) Social Security Number Untitled Co-Applicant Caretaker Name First Name Middle Name Last Name Primary Language Secondary Language Cell Telephone NumberE-mail Address(Required) Social Security Number Current Street Address Street Address City State / Province / Region ZIP / Postal Code Work Telephone NumberEmergency/Alternate NumberApplicantBirth Date MM slash DD slash YYYY Gender Female Male Race Hispanic Origin Yes No Religion/Affiliation Have You Been a Legal Tennessee Resident for the Last Six Months? Yes No Have You Lived Out of State Within the Past 5 Years? Yes No If “yes” to Living Out of State, Which State(S) and Dates? Marital Status (include date) Military Service (dates) While in Military Service, Were You Ever Convicted by a General Court Martial? Yes No Employer/In-Home Business Co-Applicant/CaretakerBirth Date MM slash DD slash YYYY Gender Female Male Race Hispanic Origin Yes No Religion/Affiliation Have You Been a Legal Tennessee Resident for the Last Six Months? Yes No Have You Lived Out of State Within the Past 5 Years? Yes No If “yes” to Living Out of State, Which State(S) and Dates? Marital Status (include date) Military Service (dates) While in Military Service, Were You Ever Convicted by a General Court Martial? Yes No Employer/In-Home Business ChildrenName First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Adults In The HomeName First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Name First Name Middle Initial Last Name Birth Date MM slash DD slash YYYY Social Security Number Primary Language Secondary Language Race Hispanic Origin Yes No Gender Female Male School/Grade or Occupation In/Out of the Home Relationship Reference Information From Individuals Living Outside The HomeApplicant Name Applicant Address Street Address City State / Province / Region ZIP / Postal Code Co-Applicant TelephoneApplicant Email Applicant Relationship Co-Applicant Name Co-Applicant Address Street Address City State / Province / Region ZIP / Postal Code Co-Applicant TelephoneCo-Applicant Email Co-Applicant Relationship Reference Name Reference Address Street Address City State / Province / Region ZIP / Postal Code Reference TelephoneReference Email Reference Relationship Reference Name Reference Address Street Address City State / Province / Region ZIP / Postal Code Reference TelephoneReference Email Reference Relationship Reference Name Reference Address Street Address City State / Province / Region ZIP / Postal Code Reference TelephoneReference Email Reference Relationship Have You Had Previous Involvement With the Department of Children’s Services? Yes No If Yes, Please Summarize Your Involvement and the Time Frame During Which This Took Place.Have You Previously Applied to Be a Foster and/or Adoptive Parent With Another Agency? Yes No If Yes, When and With What Agency?How Did You Hear About Our Agency? Type of Child You Hope to ParentGender Female Male Either Age RangeYoungest Oldest Kinship Only Yes No Sibling Group Yes No Teen Mothers Yes No Note: By end of the preparation process, the description of the child you hope to parent may change. If so, you will have the opportunity to redefine the child you feel you can most successfully parent. As a foster parent you are encouraged to update this information as you continue to redefine the child you wish to parent.LegalAre You Currently Charged With, or Have You Ever Been Convicted of, Placed on Probation or Received a Suspended Sentence in Tennessee or Any Other State forApplicanta. Any Crime Involving Children? Yes No b. Any Crime of Violence Against Another Person? Yes No c. Possession, Sale Manufacturing or Transportation of Drugs? Yes No d. Any Other Crime? (Explain) Yes No Co-Applicanta. Any Crime Involving Children? Yes No b. Any Crime of Violence Against Another Person? Yes No c. Possession, Sale Manufacturing or Transportation of Drugs? Yes No d. Any Other Crime? (Explain) Yes No Is There Any Other Information You Need to Disclose? This form is merely a statement of intentions and can be withdrawn by the applicant at any time.We do We do do not consent to the release of our names for the mailing list of foster or adoptive parent associations, training and newsletters. Signature of applicant(s) authorizes the Department of Children’s Services to contact the references listed on the application form and authorizes said references to respond to the inquiry. I certify that the information I am providing in this application is correct and complete to the best of my knowledge, information and belief. I am aware that should investigation show any falsification or misrepresentation, I will not be considered for a foster parent, or if serving as a foster parent, my home will be closed and will be disqualified from future consideration. In addition, I understand that the information on this form including my approval status may be shared or provided to other child placing agencies. Applicant’s SignatureDate MM slash DD slash YYYY Co-Applicant’s SignatureDate MM slash DD slash YYYY
