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Special Training
Do you plan to pursue further education? YesNo

If so, in what field of study?

If you did not graduate, why did you leave high school or college?

Describe the skills and abilities you possess that qualify you to represent the mission of our agency. You may also want to include civic and community activities and professional societies in which you participate.

Have you ever had a child enrolled in any Head Start or Early Head Start program? YesNo

How did you learn of this opening?

Employment History:
Please outline your last 10 years of employment below. Start with your most recent employer.

Employer Name, Address and Zip Code:
Employer Phone Number:
How Long Employed Here?
Job Title:
Supervisor Name:
Supervisor Number:
Reason for Leaving:
Summarize the type of work performed and job responsibilities:

PACT has my permission to contact and solicit information from the listed former employers and personal references. I hereby also authorize my former employers and personal references to furnish their record of service, my reason for leaving their employ, together with all information they have concerning me whether on record or not. I also release any individual, partnership or corporation which formerly employed me, its officers, agents and employers from any liability for any damage whatsoever for issuing such information.

Parent and Child Together (PACT) for West Central Illinois is an Equal Opportunity Employer.

Agency grievance procedures are available upon request to any applicant who feels they have been discriminated against on the basis of race, religion, sex, national origin or handicapping condition.