First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Phone:
Email:
Date Of Birth:
When could you start?


If hired, can you furnish proof you are eligible to work in the U.S?
Yes No


Have you ever been convicted of any crime?

A “yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will be considered.)
Yes No



If yes, give details.


Have you ever been discharged, fired, asked or forced to resign by an employer?

A “yes” answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying will be considered.)
Yes No



If yes, give details.



Do you have a high school degree or GED?
Yes No


Name of School:


Dates Attended:
to



Vocational or Technical?
Yes No


Name of School:


Choose One:
Diploma
Degree
Certificate




Years Completed:


Field of Study:


Dates Attended:
to



Did you graduate from college?
Yes No


If yes, state the name of the college and the degree received:


Years Completed:


Field of Study:


Dates Attended:
to




List any other educational qualifications you would like Little Hearts Christian Child Care Center to consider:
Employer:


From:
Mo. Year


To:
Mo. Year


Manager Name:


Address:


City:


State:


Zip Code:


phone:


Position Held:


Reason for Leaving:


List Duties/Accomplishments Performed:




Employer:


From:
Mo. Year


To:
Mo. Year


Manager Name:


Address:


City:


State:


Zip Code:


phone:


Position Held:


Reason for Leaving:


List Duties/Accomplishments Performed:




Employer :


From:
Mo. Year


To:
Mo. Year


Manager Name:


Address:


City:


State:


Zip Code:


phone:


Position Held:


Reason for Leaving:


List Duties/Accomplishments Performed:


Please give below the names of three persons not related to you. Identify all persons for whom you have performed child care services.

Reference 1
First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Phone:
Years Acquainted:


Reference 2
First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Phone:
Years Acquainted:

Reference 3
First Name:
Middle Name:
Last Name:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Phone:
Years Acquainted: