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Please Print (Fully complete both pages)
Date of Application:
Last four digits of SSN:
Last Name:
First Name:
Middle Name:
Address (street number and name):
City:
County:
State:
Zip Code:
Phone (home or where you can be reached):
Business Phone:
Position Applied For:
Date of Birth:
N. C. Driver’s License Number
Have you ever been convicted of breaking a law other than a minor traffic violation? YES____ NO____ If yes, give the date and explain fully. Use an additional piece of paper if more space is needed:
Yes
No
Have you ever had an abuse or neglect or child maltreatment substantiation? YES____ NO____ If yes, list county/State and give the date and explain fully. Use an additional piece of paper if more space is needed:
Yes
No
EDUCATION:
Schools:
Name and Location:
Dates Attended:
Coursed of Study:
Degree/Diploma:
High School:
Name and Location:
Dates Attended:
Coursed of Study:
Degree/Diploma:
College or University:
Name and Location:
Dates Attended:
Coursed of Study:
Degree/Diploma:
Graduate or Professional:
Name and Location:
Dates Attended:
Coursed of Study:
Degree/Diploma:
Educational, Vocational Schools, etc. :
Name and Location:
Dates Attended:
Coursed of Study:
Degree/Diploma:
Child care training completed in the last three years (such as First Aid, CPR, Health and Safety Training, ITS-SIDS, CDA etc.):
References:
WORK HISTORY:
Current or Last Employer:
Address:
Job Title:
Supervisor’s Name:
No. Supervised by you:
Date Employed (mo/yr):
Starting Salary:
Ending Salary:
Reason for leaving:
May we contact employer?
Yes
No
Date Separated (mo/yr):
Duties:
Full Time:
Years:
Months:
Duties:
Part Time:
Years:
Months:
Duties:
If part time, number of hours per week:
Current or Last Employer:
Address:
Job Title:
Supervisor’s Name:
No. Supervised by you:
Date Employed (mo/yr):
Starting Salary:
Ending Salary:
Reason for leaving:
May we contact employer?
Yes
No
Date Separated (mo/yr):
Duties:
Full Time:
Years:
Months:
Duties:
Part Time:
Years:
Months:
Duties:
If part time, number of hours per week:
Signature of Applicant:
Date:
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