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Do you have any physical, mental, or medical impairment or disability that would
limit your ability to perform the job for which you have applied? ____yes ____no
If yes, please explain:
___________________________________________________________________
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Have you ever been convicted of a felony, or been involved with a child abuse or
neglect court action or official investigation? _____yes _____ no
If yes, please explain:
Name: _____________________________________________________________
Address: ____________________ City ________________ State ____ Zip ______
Telephone: (day) _________________________ (night) _____________________
Name: _____________________________________________________________
Address: ____________________ City ________________ State ____ Zip ______
Telephone: (day) _________________________ (night) _____________________
Name: _____________________________________________________________
Address: ____________________ City ________________ State ____ Zip ______
Telephone: (day) _________________________ (night) _____________________
EDUCATION:
College: _____________________________________ Dates: _______________
Location: ____________________________________ Major: ________________
Degree: _________________
Special Honors/Organizations:
___________________________________________________________________
___________________________________________________________________
WORK HISTORY: (Please list your most recent employer first. Under duties,
please list specific age groups you have experience working with.)
VOLUNTEER EXPERIENCES:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
What do you feel are your strengths and weaknesses concerning working with
children?
___________________________________________________________________
___________________________________________________________________
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