Employment Application Employment Application First Name * Last Name * Date of Birth * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal How long at current address? * Mobile Phone * Email Address * Are you a U.S. Citizen? Yes No Can you prove you have a legal right to work in the U.S.? Yes No Background Information Alias (all other names used) and/or maiden name? Do you have a Colorado driver's license? Yes No Driver's license number Other states or countries you have lived in? Have you ever been convicted of a crime? Yes No If so, please explain Do you own a vehicle? Yes No Year Make Model Position Desired Full-time or Part-time? Full-time Part-time Availability Date available to Start Do you have any situation in your life that could change your availability? Yes No How far are you willing to travel? Less than 10 miles 10 miles to 25 miles 25 to 50 miles 50 miles or more Preferred cities to work? Compensation Requirements (Note: Salary levels depend on experience on education Desired hourly rate Are you willing to negotiate? Yes No Education High School attended Date graduated or attended College attended Date graduated Major Other Certifications Are you a Doula? Yes No Are you a newborn care specialist? Yes No Are you CPR certified? Yes No Are you first aid certified? Yes No Are you bilingual? Yes No If yes, what languages? Do you have any experience working with a special needs child? Yes No If yes, please explain Do you have experience with twins? triplets? Yes No Do you have children? Yes No If yes, what ages? Childcare Employment Please tell us about your childcare experiences Family Name Address Phone Number of children you cared for Ages of child(ren) when employment started Employment Start Date with this family Employment End Date with this family Family Name Address Phone Number of children you cared for Ages of child(ren) when employment started Employment Start Date with this family Employment End Date with this family Childcare References NOTE: You must have three (3) childcare references, other than family and more than as an occasional sitter Reference #1 Name Address Date Started Date Ended Phone Reference #2 Name Address Date Started Date Ended Phone Reference #3 Name Address Date Started Date Ended Phone Personal References (List two (2) personal references other than family) Reference #1 Name Length of Relationship? Relationship to you Contact phone number Reference #2 Name Length of Relationship? Relationship to you Contact phone number Health Information How is your general health? Do you smoke? Yes No Do you have any physical disability which would prevent you from performing specific kinds of work? Yes No If yes, please explain the work limitations Are you now, or have you been treated for a drug or alcohol habit? Yes No If yes, please explain Do you have or have you ever been told that you have allergies (i.e., to pets)? Yes No If yes, please explain Have you had TDAP injection within last 10 years? Please provide documentation upon request. Yes No Did you have a flu shot this year? Please provide documentation upon request. Yes No Have you received a Covid-19 vaccination? * Yes No Have you received a booster shot? Yes No I certify that the information I have furnished herein is true and accurate. Today's Date Signature of Applicant * reCAPTCHA If you are human, leave this field blank. Submit Connect with us on LinkedIn
