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Georgetown Child Development Center

Application for Employment

Date of Application: _________ Expected Rate of Pay: ________


Position being sought: _______________________
Name: _____________________________________________________________
Address: ___________________________________________________________
___________________________________________________________
Telephone: (day) ___________________ (night) ___________________________
Social Security Number: ___________________________
Email:

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:
___________________________________________________________________
___________________________________________________________________

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:

List memberships in professional or business organizations:


___________________________________________________________________
___________________________________________________________________

REFERENCES: (List names, addressed, and phone numbers of three persons


who ARE NOT related to you whom we may contact as references.)

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: _________________

High School: _________________________________ Dates: _______________


Location: ____________________________________ Diploma: ______________

Other: ______________________________________ 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.)

Employer: ____________________________________ Dates: ________________


Address: ___________________________________________________________
Supervisor’s Name: ____________________________ Phone: ________________
Position Held: _______________________________________________________
Duties: ____________________________________________________________

Employer: ____________________________________ Dates: ________________


Address: ___________________________________________________________
Supervisor’s Name: ____________________________ Phone: ________________
Position Held: _______________________________________________________
Duties: ____________________________________________________________

Employer: ____________________________________ Dates: ________________


Address: ___________________________________________________________
Supervisor’s Name: ____________________________ Phone: ________________
Position Held: _______________________________________________________
Duties: ____________________________________________________________

VOLUNTEER EXPERIENCES:

___________________________________________________________________
___________________________________________________________________
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What do you feel you might be able to bring to our Center?


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What are your expectations from our Center:


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What do you feel are your strengths and weaknesses concerning working with
children?
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