Personal Information

Your Name, Last, First, Middle: (required)

Your Social Security Number: (required)

Mailing Address: (required)

Email Address: (required)

Phone Number: (required)

Are you 18 years or older?: (required)

YesNo

Are you either a U.S. Citizen or Alien authorized to work in the U.S.? (required)

YesNo

Employment Desired

Position: (required)

Date you can start: (required)

Salary desired: (required)

Are you employed now? (required)

YesNo

If so, may we inquire of your present employer? (required)

YesNo

Have you ever applied here before? (required)

YesNo

If so, when?

Education

High School

Name and Location of School: (required)

Number of years attended: (required)

Did you graduate? (required)

YesNo

Subjects studied: (required)

College

Name and Location of School: (required)

Number of years attended: (required)

Did you graduate? (required)

YesNo

Subjects studied: (required)

CDA Credential or other Early Childhood Education

Name and Location of School: (required)

Number of years attended: (required)

Did you graduate? (required)

YesNo

Subjects studied: (required)

Former Employers (List below your last three employers, starting with the most recent)

Most Recent Employer

Name & Address of Employer: (required)

Start Date Month & Year: (required)

End Date Month & Year: (required)

Salary: (required)

Position: (required)

Reason for leaving: (required)

Second Most Recent Employer

Name & Address of Employer: (required)

Start Date Month & Year: (required)

End Date Month & Year: (required)

Salary: (required)

Position: (required)

Reason for leaving: (required)

Third Most Recent Employer

Name & Address of Employer: (required)

Start Date Month & Year: (required)

End Date Month & Year: (required)

Salary: (required)

Position: (required)

Reason for leaving: (required)

References: Names of three persons not related to you, whom you have known for at least a year

Reference #1 (Please list name, mailing address and telephone number): (required)

Reference #2 (Please list name, mailing address and telephone number): (required)

Reference #3 (Please list name, mailing address and telephone number): (required)

Physical Record:

Do you have any physical limitations that preclude you from performing any work for which you are being considered? (required)

YesNo

If yes, what can be done to accommodate your limitation (Please describe):

In case of emergency, please contact (full name, mailing address and phone number): (required)

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.
I authorize investigation of all statements contained herein and the references listed above 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. I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice.

YesNo