PAL-A-ROO'S

UNIVERSITY CITY  ON-LINE   EMPLOYMENT  APPLICATION

Social Security Number:    Last Name:
First Name:    Middle Initial:
Address:
City:    State:
Zip Code:   County:
Phone:   Business Phone:
E-Mail Address:

Position Applied for:

Full Time    Part Time   Either
Approximate Number of Hours Desired per Week:
Date of Birth (MM/DD/YYYY):
Driver's License Number:    Driver's License State:

Have you ever been convicted of breaking the law other than a minor traffic violation?  
Yes   No
If Yes, give date and fully explain:

Please list child care training you have completed in the last three years (such as first aid, CPR, CDA, etc.):

What hours do you prefer to work?
What days do you prefer to work? 
With what age group do you prefer to work?
 (Hold Down Ctrl Key to Click on Multiple Choices)

Highest Grade Completed:

School Type Name & Location Dates Attended Course of Study Degree or Diploma
High
School

 

 From:
To:  
College or University

 

 From:
To:   
Graduate or Professional

 

 From:
To:  
Educational, Vocational, etc.

 

 From:
To:   

REFERENCES

List the names, addresses and phone numbers of two personal references, excluding relatives, we may contact:
Ref 1:
Ref 2:

List the names, addresses and phone numbers of two co-workers, excluding relatives, we may contact:
Ref 1:
Ref 2:

WORK HISTORY
(list child care/early childhood experience first including volunteer work)

Employer:
Address: 
Job Title:
Supervisor's Name:
Number Supervised by you:
Date Employed (MM/YY):   Date Separated (MM/YY):
Starting Salary:   Ending Salary:
Did you work Full Time?  Yes   No   For How Long?
Did you work Part Time?  Yes   No   For How Long?
If Part Time, how many hours did you work per week?
Reason for Leaving:
May we contact this employer?  Yes   No 

Employer:
Address: 
Job Title:
Supervisor's Name:
Number Supervised by you:
Date Employed (MM/YY):   Date Separated (MM/YY):
Starting Salary:   Ending Salary:
Did you work Full Time?  Yes  No   For How Long?
Did you work Part Time?  Yes   No   For How Long?
If Part Time, how many hours did you work per week?
Reason for Leaving:
May we contact this employer?  Yes   No 

Employer:
Address: 
Job Title:
Supervisor's Name:
Number Supervised by you:
Date Employed (MM/YY):   Date Separated (MM/YY):
Starting Salary:   Ending Salary:
Did you work Full Time?  Yes   No   For How Long?
Did you work Part Time?  Yes   No   For How Long?
If Part Time, how many hours did you work per week?
Reason for Leaving:
May we contact this employer?  Yes   No 

How did you hear about us?

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 investigation 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 legal action.  I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications.

Signature of Applicant ____________________________ Date _____________
(Signature will be obtained if you are invited for an on-site interview)