WPCC Application for Employment

List the the names, phone numbers & emails of THREE people we may contact as references:

Work History #1

If you have not had work history please include internships or volunteer experience you have had related to early childhood.

Current or Last Employer*

Address

Job Title*

Supervisor's Name*

Are you still employed with this company?*

YESNO

Date Employed*

Date

Date Separated

Date

Reason for Leaving

May we contact your employer?*

YESNO

Starting Salary*

Please include per week, per hour, per month, etc. as applicable

Ending Salary*

Please include per week, per hour, per month, etc. as applicable

Did you work full-time or part-time?*

Full-TimePart-Time

If you worked part-time, how many hours per week did you work on average?

Please list duties you were responsible for*

Work History #2

If you have not had work history please include internships or volunteer experience you have had related to early childhood.

Current or Last Employer

Address

Job Title

Supervisor's Name

Date Employed

Date

Date Separated

Date

Reason for Leaving

May we contact your employer?

YESNO

Starting Salary

Please include per week, per hour, per month, etc. as applicable

Ending Salary

Please include per week, per hour, per month, etc. as applicable

Did you work full-time or part-time?

Full-TimePart-Time

If you worked part-time, how many hours per week did you work on average?

Please list duties you were responsible for

Please share any additional information that you believe may be pertinent or that you would like to share.

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 investigations 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) criminal action. I further understand that dismissal on unemployment shall be mandatory if fraudulent disclosures are given to meet position qualifications.

Signature*

Date*

Date

WPCC Application for Employment

Education

High School

Undergraduate Degree

Graduate Degree

Education, Vocational Schools, etc.

References & Work History

Work History #1

Work History #2