Employment Application

What position are you applying for?*
General Information
Name*
First Last
Are you at least 21 years old? (You must be 21 to work here.)*
- Yes
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*

Employment History (Most Current First)
Position 1
Company*
Position*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Salary*
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Reason For Leaving*
Primary Supervisor*
May We Contact This Employer?*
- Yes
- No
Phone
Email
Position 2
Company
Position
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Salary
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason For Leaving
Primary Supervisor
May We Contact This Employer?
- Yes
- No
Phone
Email
Position 3
Company
Position
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Salary
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason For Leaving
Primary Supervisor
May We Contact This Employer?
- Yes
- No
Phone
Email

Personal References (please do not list family members)
Childplace must make contact with three references.
I authorize Childplace Staff to contact the following references*
- Yes
- No
Reference 1
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Length of Time Known*
Phone*
Email*
Reference 2
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Length of Time Known*
Phone*
Email*
Reference 3
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Length of Time Known*
Phone*
Email*
Reference 4
Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Length of Time Known
Phone
Email

Most positions at Childplace, INC. require transporting clients; therefore, the following information is investigated to determine company vehicle usage:
Do you currently hold a valid drivers license?*
- Yes
- No
State that issued license?
Full Name as it appears on License
Name
First Last
Driver's License Number
Date of Birth
MM slash DD slash YYYY
How many moving traffic violations have you had in the last five years?
Dates and Types of Violations:
Any tickets for careless or reckless driving?*
- Yes
- No
Date(s):
How many accidents have you had in the last five years?
Dates and Person at Fault:
Has any company canceled or refused to issue or renew auto insurance to you?*
- Yes
- No
Explain
Have you ever had a suspended or revoked drivers license?*
- Yes
- No
Briefly Explain

General Information