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