Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Available *

MM

DD

YYYY

Are you at least 18 years or older? *

Yes

No

Are you willing to work overtime? *

Yes

No

Do you have current CPR/ First Aid? *

Yes

No

Any person working in licensed childcare in the state of Georgia must pass a national background check. Have you ever been convicted of any criminal offense other than a minor traffic violation? *

Yes

No

Notice *

By completing this form, I am affiriming that the information provided on this application (and acoompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions in my application or in the interview may disqualify me from further consideration for employment and my be considered justification for dismissal if discovered at a later date. I authorize persons, schools, my current employer (if applicable) and previous employers and organizations names in this application (and accompanying resume, if any) to provide any relevant information that may be required to arrive at an employment decision. In consideration of my employment, I agree to confirm to the policies and rules of this company and further agree and understand that my employment can be terminated, with or without cause, at any time at the discretion of the employer or myself.*

I Agree

I Do Not Agree