Employment Application

Applicant Information                                                                                                                                            

First Name:
MI:
Last Name:
Address:
City:
State:
Zip:
Are you at least 18 yrs of age? Yes No
Phone:
Email:
Date Available:
Driver's License No.:
Desired Salary:
Position Applied for:
Shift: Morning Afternoon No Preference
Are you a citizen of the United States?
Yes No
If no, are you authorized to work in the U.S.?
Yes No
Have you ever had a Department of Social Services substantiation?
Yes No
If yes, must provide county, state, date and explanation upon request.
Have you ever been convicted of breaking the law other than a minor traffic violation?
Yes No
If yes, must provide dates and explanation upon request.

Education                                                                                                                                                                

High School:
State:
Zip:
From:
To:
Did you graduate?
Yes No
Degree:
College:
State:
Zip:
From:
To:
Did you graduate?
Yes No
Degree:
Other:
State:
Zip:
From:
To:
Did you graduate?
Yes No
Degree:

References                                                                                                                                                             

Please list three professional references.
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address
Full Name
Relationship
Company
Phone
Address

Previous Employment                                                                                                                                          

Company
Phone Number
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes No
Company
Phone Number
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes No
Company
Phone Number
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for Leaving
May we contact your previous supervisor for a reference?
Yes No

Training, Professional Development, Certifications, Credentials, etc.                                                           

List any child care training completed in the last three years (such as CPR, CDA, ITS-SIDS, Conscious Discipline, Galileo, etc.)

Other Skills and Abilities                                                                                                                                      

Indicate if you are proficient in the following:
Technology Applications (Apps) MS Word MS Excel MS PowerPoint Email
Other:

Disclaimer and Signature                                                                                                                                     

I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigations of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures are given to meet position qualifications.
Type Full Legal Name
Date