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Fields marked with an * are required University City Employment Application Applicant Information First Name: * Middle Initial: Last Name: * Date Of Birth: (mm/dd/yyyy) * Contact Information Home Street Address: * Apt/Suite #: City: * State: * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code: * Phone Number: * Email Address: * Applicant Driver's License Information Do You Have A Driver's License? * Yes No Driver's License Number: State Issued: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Position Applying For Date Available To Work: Position Applying For: Lead Teacher Teacher's Assistant Cook Director Assistant Director Type Of Employment Desired: Full-Time Part-Time Temporary What Age Groups Would You Prefer To Work With? Infants 2-Year-Olds 3-Year-Olds 4/5-Year-Olds School-Aged Preferred Work Days: MondayTuesdayWednesdayThursdayFriday Number Of Hours Desired: * Preferred Work Hours: All Training Courses Completed In The Last 3 Years: Eduction Name Of High School: * High School Address (City): * High School Address (State): * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Dates Attended: * High School Certifications: * DiplomaGEDNone College/University: Course Of Study: Dates Attended: Degree/Diploma: DegreeDiplomaNone Graduate/Professional: Dates Attended: Course Of Study: Degree/Diploma: DegreeDiplomaNine Educationl/Vocational: Dates Attended: Course Of Study: Degree/Diploma: DegreeDiplomaNone Diplomas, Certificates, or Degrees Obtained Work History Employer: Employer Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code: Job Title: Supervisor Name: Dates Employed: (To/From) Starting Salary/Hourly Rate: Ending Salary/Hourly Rate: Was This A Full-Time Or Part-Time? Full-TimePart-Time Reason For Leaving? May We Contact Employer? YesNo Employer: Employer Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code: Supervisor Name: Dates Employed: (To/From) Starting Salary/Hourly Rate: Ending Salary/Hourly Rate: Was This A Full-Time Or Part-Time? Full-TimePart-Time Reason For Leaving: May We Contact Employer? Yes No Other Information Have You Ever Been Convicted Of Breaking The Law Other Than A Minor Traffic Violation? * YesNo If Yes, Please Give Date & Explain. References List The Names, Addresses And Phone Numbers Of Two Personal References, Excluding Relatives, We May Contact: * List The Names, Addresses And Phone Numbers Of Two Co-Workers, Excluding Relatives, We May Contact: * Legal Agreement I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event that confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, 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, in addition to potential legal action. I further understand that dismissal upon employment shall be mandatory if fradulent disclosures are given to meet position requirements. * Yes, I certify that the above information is true, accurate, and complete to the best of my knowledge. Signature* Date: (mm/dd/yyyy)
