Northwest Montana Head Start, Inc.
79 Seventh Avenue East North
Kalispell, MT 59901
Phone (406) 752-7011
FAX (406) 755-1916
We are an Equal Opportunity Employer and Provider and fully subscribe to the principles of Equal Employment Opportunity. Applicants and/or
employees are considered for hire, promotion and job status, without regard to race, color, ethnicity, religion, gender, marital status, national origin, age,
physical or mental disability, political beliefs, genetic history or any other protected characteristic as established by law.
Please download document, double click in gray boxes and type your information in the ‘default text’ box, then click OK.
NAME:
DATE OF APPLICATION:
LAST/FIRST/M.I.
MAILING ADDRESS:
CITY:
STATE:
ZIP:
CELL:
MAIN PHONE:
1. GENERAL INFORMATION
Position applying for, please be specific:
Date available:
Are you able to perform the essential job functions of this position with reasonable accommodations?
Yes
No
A criminal record or conviction will NOT automatically bar employment but will be considered only as it reasonably relates to your fitness to
perform in this position.
Have you been convicted of any felonies during the past 7 years?
Yes
No If yes, please explain:
2. EDUCATION AND TRAINING
Please provide a copy of your TRANSCRIPTS to verify qualifications and ensure accurate placement on the wage scale.
Highest grade completed:
High School/GED
Name of School
High School
College--
1 yr
2 yrs
City/State
3 yrs
4 yrs
Masters
Your Degree
Doctorate
Major
College/University
College/University
Other (Tech., Vocational, Certification Programs)
List any scholarships, academic honors, awards, or special achievements:
3. Please check below and provide copies of current certificates/licenses you have.
First Aid card
Yes
No
CPR card
Yes
No
Commercial Driver’s License (CDL)
4. SKILLS
Please list any skills you have that are appropriate for this position:
Yes
No
5. HEAD START EXPERIENCE
Parent
Staff
Area of Program:
Bus
Office
Volunteer
Practicum Student
Classroom
Family Services
Other:
Kitchen
Other:
6. Explain fully why you believe you are qualified for this position.
7. INTERESTS/ACCOMPLISHMENTS
List any experiences, interests, and accomplishments gained while working as a volunteer or hobbyist that may be useful in this
position.
8. EMPLOYMENT HISTORY
Please fill out this section completely and do not write “see resume.” Begin with your most recent employment. Please include a
separate resume that shows your complete work history.
Name/Address of Company
Name and Title of Supervisor
Company Phone Number
Your Title
Employed
From
To
Reason for Leaving
Salary
Beg
End
per month
per month
Employed
From
To
Reason for Leaving
Salary
Beg
End
per month
per month
Employed
From
To
Reason for Leaving
Salary
Beg
End
per month
per month
List jobs held, duties performed, skills used, and promotions while employed by this company
Name/Address of Company
Name and Title of Supervisor
Company Phone Number
Your Title
List jobs held, duties performed, skills used, and promotions while employed by this company
Name/Address of Company
Name and Title of Supervisor
Company Phone Number
Your Title
List jobs held, duties performed, skills used, and promotions while employed by this company
9. If you do not want us to contact any of the previously listed current or former employers, please list below and
state the reason you do not want each contacted.
10. PROFESSIONAL REFERENCES—Please list three people you have worked with that we may call as references.
Name and Company
Address
Phone
l
11. FOR TEACHER AND TEACHER AIDE APPLICANTS
What age children have you worked with?
Have you ever been involved with or have you ever implemented developmentally appropriate curriculum?
Yes
No
Please list any additional experience you have with young children (volunteering, child care, family, etc.)
Is there any other information you would like us to know about you?
FOR EMAIL SUBMISSIONS:
(double click on box—select “checked” under default value) By checking this box and dating below, I certify
the information contained in this application is correct to the best of my knowledge and understand that any
misstatement or omission of information may result in denial of employment or discharge. I authorize the
references listed to give you any and all information concerning my previous employment and any pertinent
information they may have, personal or otherwise, and release all parties from all liability for any damage that may
result from furnishing same to you.
Date
Please email your completed application to asst@nwmtheadstart.org or return printed application to Northwest
Montana Head Start – 79 Seventh Avenue East North – Kalispell, MT 59901. Thank you.
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Revised 11/8/11