Employment Application

Step 1 of 4

25%

Applicant Information

Name

First Middle Last

SSN

Please enter a number from 0 to 999999999.

Birthdate

Month123456789101112

Day12345678910111213141516171819202122232425262728293031

Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

All Previous Names (if any, including aliases and maiden name)

Home Address

Street Address City State / Province / Region ZIP / Postal Code

Mailing Address or P.O. Box

Street Address City State / Province / Region ZIP / Postal Code

Phone Number

Alternate Phone Number

Email

Education

Do you have a high school diploma, General Education Development (GED) credential, or Licensing approved equivalent?

Yes

No

If No, are you in the process of obtaining a high school diploma, General Education Development (GED) credential, or Licensing approved equivalent?

Yes

No

What is the highest grade you have completed?

List of child care credentials or educational certificates

Credential or Certificate

Expiration Date (mm-dd-yyyy)

 

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College

College/University/School

Location

Degree

Major/Minor

Start of Attendance

End of Attendance

Graduation

Number of completed semester hours if you did not graduate

Previous Child Care Employment

Employer Information

Employer Name

City, State, ZIP

Phone

Full Time or Part Time?

Start Date

End Date

 

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References

List at least three (3) non-relative references, with at least two (2) from your most recent employment, if applicable.

Name (Reference 1)

First Last

Phone

Relationship

Address

Street Address City State / Province / Region ZIP / Postal Code

Name (Reference 2)

First Last

Phone

Relationship

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Name (Reference 3)

First Last

Phone

Relationship

Address

Street Address City State / Province / Region ZIP / Postal Code

Agreement

I understand that giving false or incomplete information may result in denial or revocation of my license.

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