Full Address:

Employment Information

Type of employment desired:
Full-timePart-timeTemporary

Position(s) Applied For:*

Date you are available to start work:*

Are you able to meet the attendance requirements? YesNo

Do you have any objection to working overtime if necessary? YesNo

Have you ever been previously employed by our company? YesNo

Can you submit proof of legal employment authorization and identity? YesNo

If you are under 18, can you furnish a work permit if it is required? YesNo

Have you ever been convicted of a crime? YesNo

If yes, please explain (a conviction will not automatically bar employment.)

How were you referred to us?

Employment History

Please provide all employment information for your past two employers starting with the most recent.

Employer 1:

Employer Full Address:

Job Summary:

Reason for Leaving:

Employer 2:

Employer Full Address:

Job Summary:

Reason for Leaving:

Certification History

Have you completed ECE 1? YesNo

Have you completed ECE 2? YesNo

Do you have a Department of Education Certification as an Early Care Intern? YesNo

...as an Assistant Teacher? YesNo

...as a Lead Teacher? YesNo

...as a Curriculum Coordinator? YesNo

...as an Administrator? YesNo

Certification Information

Have you completed First Aid? YesNo

Expiration Date:

Have you completed CPR? YesNo

Expiration Date:

Have you completed ServSafe? YesNo

Expiration Date:

Have you completed Administration of Medication? YesNo

References

Do not include relatives or employers.

1. Name:

2. Name:

3. Name:

Any additional questions and/or comments you would like to add?