CHILDREN OF PURPOSE STEM ACADEMY

CHILDREN OF PURPOSE STEM ACADEMY
A PPLICA NT INFOR M A TION
Last Name
First
M.I.
D.O.B
Street Address
Apartment/Unit #
City
State
Phone Number

Area Code Phone Number
E mai Address
Date Available

Month Day Year
Date
Shift Preference:
Position Applied for
Desired Salary
Are you a citizen of the United States?

YES ( ) NO ( ) If no, are you authorized to work in the U.S.? YES ( )
Have you ever worked for this company?

YES ( ) NO ( ) If so, when?

Have you ever been convicted of a felony? YES ( ) NO ( )
If yes, explain
EDUCA TION
High School
College
From
To
Degree
Other
Address
To

Did you graduate? YES ( ) NO ( )
REFERENCES
Please list three professional references.
Ful Name
Relationship
Phone
Full Name
Company
CHILDREN OF PURPOSE STEM ACADEMY
PR EVIOUS EARLY CHILDHOOD EDUCA TION EMPLOYMENT
Company
Address
Job Title
May we contact your previous supervisor for a reference?

YES ( ) NO ( )
Phone
Responsibilities
From
Reason for Leaving
May we contact your previous supervisor for a reference?

YES ( ) NO ( )
Supervisor
Starting Salary
Ending Salary
May we contact your previous supervisor for a reference?
DIS CLA IM ER A ND S IGNATUR E
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employ ment, I understand that false or misleading information in my application or interv iew may result in my release.
Signature

Clear
Date

Month Day Year
Date
Phone Number

Area Code Phone Number
Should be Empty: