Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Position You are Applying For
*
Lead Teacher
Assistant Teacher
Cook
Assistant Director
Date of Birth
*
MM
DD
YYYY
Last 4 digits of SSN
*
North Carolina Driver's License Number
*
Have you ever been convicted of breaking the law other than a traffic violation?
*
If yes, give the date and explain fully:
Have you ever had an abuse or neglect or child maltreatment substantiation?
*
If yes, list county/State and give the date and explain fully:
If you selected 'other' share highest level completed here:
High School Name & Location
Dates Attended
Course of Study
Type of Degree or Diploma
College or University Name & Location
Dates Attended
Course of Study
Type of Degree or Diploma
Graduate or Professional School
Dates Attended
Course of Study
Type of Degree or Diploma
Educational, Vocational Schools etc.
Dates Attended
Course of Study
Type of Degree or Diploma
Child care training completed in the last three years (such as First Aid, CPR, Health and Safety Training, ITS-SIDS, CDA etc.):
References
*
List the names, addresses, and phone numbers of people we may contact as references:
Current or Last Employer
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
Supervisor's Name
First Name
Last Name
Number of employees supervised by you:
Reason for leaving:
May we contact employer?
Starting Salary
Ending Salary
Job duties:
If part time, number of hours per week:
Current or Last Employer
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
Supervisor's Name
First Name
Last Name
Number of employees supervised by you:
Reason for leaving:
May we contact employer?
Starting Salary
Ending Salary
Job duties:
If part time, number of hours per week:
Date you can start:
*
MM
DD
YYYY
Please add your work availability here:
*
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.
*
Signature
*
First Name
Last Name
Date of Application
*
MM
DD
YYYY
