Today's Date:
Applying for: Full-Time Part-Time Temporary
Position Applying for:
Date available for employment:
Your Full Name:
Current Address:
City: State: Zip:
Contact & Other Information:
Home Phone:
Cell Phone:
Email:
Us CItizen: Yes No
Do you have a Soc. Sec. Number?: Yes No
Date of Birth:
Employment History
1) Current or Most Recent Employer :
Your Position:
How Long? From: to:
Starting Wage:
Employers Address:
Employer’s Phone:
Okay to contact this Employer? Yes No
Contact Person:
Reason for leaving or looking for other job:
2) Previous Employer :
3) Previous Employer :
Personal References (3)
(1) Name Phone:
Relationship How Long?
(2) Name Phone:
(3) Name Phone:
Education:
Highest Grade Level Completed:
(High School) 9 10 11 Grad GED
(College) 1 2 3 4 Degree:
Tell me about all applicable education and classes completed.
Tell me about any experience you have working with children.
What ages of children are you most comfortable working with?
Are you trained in Pediatric CPR and 1st Aid? Yes No
Are you willing to participate in ongoing training? Yes No
Are you currently enrolled in the Oregon Criminal History Registry? Yes No
(note: you will not be eligible for an interview without being enrolled in the registry) PLEASE DO NOT LINK YOURSELF TO OUR CHILD CARE.
Registry Number: Expires:
Have you ever been convicted of a crime? Yes No
If Yes, please explain:
Are you willing to take a urinalysis for drug testing? Yes No
Are you able to perform all the required functions of this position? Yes No
If No, please explain :
I have answered these application questions fully and honestly and would like to be considered for a position at My Bundle of Joy. You have my permission to check all references and verify all information given here. (Please fill-in your Full Name)
Signed: Date: