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Employment Application

Employment Form

First Name

Last Name

Date

Upload Resume

Upload your resume [10MB limit]

Current Address

Address Line 1

City

State

Zip Code

Phone/Mobile

Email Address

Position(s) applying for

Hourly rate of pay expected

$

/hr

Are you at least 18 years of age?

Yes

No

How did you learn of this opening?

Name of any relatives employed by Lewis County Head Start

Do you have or are you willing to get a COVID vaccine?

Yes

No

If no, are you interested in a religious or medical exemption?

Yes

No

Have you ever been convicted of a misdemeanor or felony in any state?

Yes

No

If yes, describe in full

Education Background

Name of School

Address of School

Course of Study

Did you Graduate

Yes

No

Years Completed

List Degree or Diploma

Add more education

Name of School

Address of School

Course of Study

Years Completed

Did you Graduate

Yes

No

List Degree or Diploma

Add more education

Name of School

Address of School

Course of Study

Years Completed

Did you Graduate

Yes

No

List Degree or Diploma

Professional Work References

Name of Reference and Occupation

Address

Address Line 1

City

State

Zip Code

Phone Number

Email

Add another reference

Name of Reference and Occupation

Address

Address Line 1

City

State

Zip Code

Phone Number

Email

Add another reference

Name of Reference and Occupation

Address

Address Line 1

City

State

Zip Code

Phone Number

Email

Prior Work History [list more recent first]

Employer's Name

Employment Location

City

State

Supervisor's Name and Title

Employer's Phone Number

Work Details

Reason for Leaving

Add work history

Employer's Name

Employment Location

City

State

Supervisor's Name and Title

Employer's Phone Number

Work Details

Reason for Leaving

Add work history

Employer's Name

Employment Location

City

State

Supervisor's Name and Title

Employer's Phone Number

Work Details

Reason for Leaving

Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with Lewis County Head Start?

Occasionally the form of an application makes it difficult for an individual to adequately summarize his/her complete background. Please use the space below to summarize any additional information necessary to describe your full qualifications (e.g. – additional education and training, community involvement, extra-curricular activities, etc.).

The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex, or national origin. Age Discrimination in Employment Act of 1967 prohibits discrimination because of age. Thank you for completing this application and for your interest in employment with Lewis County Head Start. Please be assured that your opportunity for employment will be given every consideration. Applicant’s Certification for Agreement (Please read carefully) I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be considered sufficient cause for dismissal.

Signature of Applicant (E-Signature)

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Contact Form

First Name

Last Name

Email

Phone

Program or Location

Beaver Falls Head Start

BOCES Head Start

Early Head Start Home Base

Early Head Start Class

Lowville Class 1

Lowville Class 2

Lyons Falls Head Start

Your Message

Main Office:

7671 North State Street
Lowville, NY 13367

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Phone:

315-376-7531, option 5

Click Here To Call

Directory of Services:

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Email:

sgiver@lchskids.org

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