Head Start Health Services Manager

• Did you graduate high school or do you have a high school equivalency diploma?
• Did you graduate high school or do you have a high school equivalency diploma? YES NO

License (to include drivers), certificate, or other authorization to practice a trade or profession:

• Type
• License Number
• Expiration Date
• Granted By

Please list three professional references.

Starting with the most recent, describe all paid, military, and applicable volunteer experience. You may list significantly different jobs within the same organization as separate items.

• Job Title *
• Employer *
• Address *
• Phone *
• Type of Business *
• Hours worked per week *
• Duties *
• Reason For Leaving *
• Date Start (mo/yr) *
• Beginning Salary *
• Date End (mo/yr) *
• Ending Salary *
• Name *
• Title *
• E-mail

I consent to this supervisor being contacted regarding this application for employment. I further give my permission for this supervisor to give a reference regarding my present or previous work experience. Please do not contact this supervisor.

• Have you ever been discharged, forced to resign, or failed to have an employment contract renewed?
• Have you ever been discharged, forced to resign, or failed to have an employment contract renewed? YES NO
• Are you or a member of your immediate family currently a member of the STEP Incorporated Board of Directors or of the STEP Incorporated Head Start Policy Council?
• Are you or a member of your immediate family currently a member of the STEP Incorporated Board of Directors or of the STEP Incorporated Head Start Policy Council? YES NO
• Do you have any relatives working for Step?
• Do you have any relatives working for Step? YES NO

When will you be able to begin work?

Please use this space to provide additional information about your qualifications or to amplify statements made in this application:

I hereby certify that all entries given in this application are true and complete, and I agree and understand that anyfalsifications of information herein, regardless of time of discovery, may cause forfeiture of my part of any employment in the service of STEP Incorporated, I understand that all information on this application is subject to verification.