STATE OF LOUISIANA DEPARTMENT OF CHILDREN AND FAMILY SERVICES

SCR-1 LIC
Rev. 01/13
06/11 Issue Obsolete
STATE OF LOUISIANA
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
STATE CENTRAL REGISTRY DISCLOSURE FORM
This form must be completed by each individual owner, operator, administrator, current or prospective employee or
volunteer of a child care facility or juvenile detention facility licensed by the Louisiana Department of Children and Family
Services for themselves, Any owner, operator, administrator, current or prospective employee, or volunteer of a child care
facility or juvenile detention facility licensed by the department who knowingly falsifies the information on the State Central
Registry Disclosure Form shall be guilty of a misdemeanor offense and shall be fined not more than five hundred dollars, or
imprisoned for not more than six months, or both. R.S. 46:1414.1.C or R.S. 15:1110.2(C).
This form shall be maintained by the owner /operator of the licensed facility in accordance with current licensing standards
as mandated by R.S. 46:1414.1.B or R.S. 15:1110.2.(B).
Name of Licensed Facility (Print or Type)
License #
Physical Address of Licensed Facility
Name of Individual/Applicant (Print or Type)
Date of Birth
Social Security#
Maiden, Previous or Any Other Name Used
Race
Sex
Current Street Address
City and State
Zip Code
Most Recent Previous Address
City and State
Zip Code
(
)
(
Current Home Phone #
)
(
Current Cell Phone #
)
Work Phone #
My Name
is
is not
(check one)
currently recorded as a perpetrator on the State Central Registry for what the Department of Children
and Family Services (DCFS) has determined to be a justified (valid) finding of child abuse or neglect.
I
been determined to have a justified (valid) finding of abuse or neglect since the Risk Evaluation
Panel finding.
have
have not
If the DCFS Licensing Section has reasonable suspicion or is provided with facts or information
that your name is on the State Central Registry as a perpetrator with a valid/justified finding
of abuse and/or neglect, the Licensing Section may request a clearance of the SCR without your
permission. If your name does in fact appear on the SCR as described above, the department
will notify both your employer (the facility named above) and the appropriate District
Attorney's Office of your failure to comply with R.S. 46:1414.1 and R.S. 15:1110.2
The information given is true and complete to the best of my knowledge.
Signature
Date
Signature of the Licensed Facility Representative
Date
APPLICATION FOR EMPLOYMENT
St. Martin, Iberia, Lafayette, Community Action Agency, Inc
Post Office Box 3343
Lafayette, LA. 70502-3343
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age marital or veteran status,
the presence of a non-job-related medical condition or handicap, or an other legally protected status.
"An Equal Oppertunity Employer - Program"
"Auxiliary Aids Available Upon Request To Individuals With Disabilities"
Application must be completed in full. Resume and other information may be attached but will not be considered in Lieu of a formal Application
(Please Print)
Date of Application :
Position Applied For :
Referral Source :
Advertisement
Friend
Relative
Walk - in
Employment Agency
Other
Name :
First
Address :
Telephone :
(
Number
Middle
Street
)
Last
City
State
Social Security Number :
Zip Code
Are you related to anyone employed by this agency or a member of the SMILE Head Start Policy Council, RSVP Advisory
Council, or Board of Directors?
Yes
No
If Yes, Who ?
Relation :
Are you a current or former Early Head Start and/or Head Start parent ?
If employed and you are 18, can you furnish a work permit ?
Yes
If necessary, best time to call you at home is :
Have you filed an application here before ?
Have you ever been employed here before ?
Are you employed now ?
Yes
No
Yes
No
A.M or
Yes
No
Yes
No
P.M
If Yes, give date
No
If Yes, give date
May we contact your present employer ?
Yes
No
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status ?
Yes
No
Proof of citizenship or immigration status will be requested upon employment.
On what date would you be available for work ?
Are you available to work ?
Full Time
Are you on a lay - off and subject to recall ?
Salary expected : $
Part Time
Yes
Shift Work
No
(hr., wk., mo.)
Temporary
Can you travel if a job requires it ?
Have you been convicted of a felony within the last 7 years ?
If applying for a driver position
per
Yes - If Yes, please explain
CDL License #
Yes
No
Chauffeurs License#
Endorsements
1
No
EMPLOYEMENT HISTORY
List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience.
Employer
Telephone (
From
Hourly Rate/Salary
Starting
$
Per
Job Title
Immediate Supervisor and Title
Hourly Rate/Salary
Final
Reason for Leaving
$
May we Contact for References ?
Yes
Per
No
Employer
Later
From
Dates Employed
To
Summarize the nature of the work
performed and job responsibilities
)
Address
Hourly Rate/Salary
Starting
$
Per
Job Title
Immediate Supervisor and Title
Hourly Rate/Salary
Final
Reason for Leaving
$
May we Contact for References ?
Yes
Per
No
Employer
Telephone (
Summarize the nature of the work
performed and job responsibilities
)
Address
Telephone (
Dates Employed
To
Later
From
Dates Employed
To
)
Address
Hourly Rate/Salary
Starting
$
Per
Job Title
Immediate Supervisor and Title
Hourly Rate/Salary
Final
Reason for Leaving
May we Contact for References ?
$
Yes
No
Per
Later
2
Summarize the nature of the work
performed and job responsibilities
List any foreign language (s) you know or speak and check the boxes that describe your skills level.
Language
Speak Some
Speak Fluently
Read
Write
List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race,
religion, national origin, age, color, disability or other protected status.)
Organization
Offices Held
List professional, accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national
origin, age, color, disability, or other protected status.)
References
List name and telephone number of three business/work references that are not related to you and are not previous supervisors. If not applicable ,
List three school or personal references that are not related to you.
Name
Telephone
Years Known
Skills and Qualifications
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work for our agency.
Typing Speed
wpm
Short hand
wpm
Dictating Skills
wpm
Educational Background
A. List last (3) schools attended, starting with last one. B. List number of years completed. C. Indicate degree or diploma earned, if
any. D. Grade Point Average or Class Rank. E. Major and Minor field of study (if applicable).
A. School
B. No. Year
Completed
C. Degree or
Diploma
D. GPA Class Rank
E. Major
E. Minor
List any additional information you would like us to consider. Honors Received : State any additional information you feel may be
helpful to us in considering your application.
Applicant's Statement
I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained
in this application for employment as may be necessary in arriving at an employment decision.
The applicant understands that neither this document nor any offer of employment from the employer constitute an employment contract.
In the event of employment, I understand that false or misleading information given in my application or interview (s) may result in
discharge. I understand , also, that I am required to abide by all rules and regulations of the employer.
Signature of Applicant
3
Date
For Human Resources Department Use Only
Positions (s) applied for
Available
Other Positions considered for :
Hired :
Yes
No
Position hired for
EEO Classification
1. Officials and Managers
2. Professionals
3. Technicians
4. Sales Workers
5. Administrative Support Workers
6. Craft Workers (Skilled)
7. Operatives (Semi-Skilled)
8. Laborers (Unskilled)
9. Service Workers
Notes :
Completed by :
Date :
4
Date of Hire :
Not Available
Voluntary Affirmative Action Information
Applicant's Name :
First
Telephone : (
Middle
Last
)
Address :
Street
City
State
Zip Code
As required, we comply with government regulations including Affirmative Action Obligations where they apply.
In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations, we ask
that you complete this applicant data survey. Your cooperation is appreciated.
Please be advised that your survey is not a part of your official application for employment. It is considered confidential
information that will not be used in any hiring decision.
Check one :
Male
Female
Check one of the following Race/Ethnic Group :
Hispanic
Black
White
American Indian/Alaskan Native
Asian/Pacific Islander
SPECIAL NOTICE TO VIETNAM ERA VETERANS, DISABLED VETERANS AND INDIVIDUALS WITH PHYSICAL OR
MENTAL HANDICAPS OR DISABILITIES:
Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are
required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam
Era, and handicapped individuals.
You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable
accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect
your consideration for employment.
If you so wish to be identified, please check if any of the following are applicable :
Vietnam Era Veteran
Disabled Veteran
Individual with a Disability
To be completed by applicant - Not for interview purposes - To be filed separately from application.
This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Act or necessitated by
another federal law or regulation.
SUBMIT
5