Social Security Number
Last Name
First Name
Middle Name
Address (street number and name)
City
County
State
Zip Code
Phone 1

Phone 2
Position Applied For:
Have you previously worked for any SPEC location: Yes No
If Yes, please specify location:
If hired, do you have a preference for what city you would like to work? If so, list it below:
Date of Birth: Driver's License Number: State Issued In:
Email Address:
How did you hear about us?

Have you ever been convicted of breaking the law other than minor traffic violation? (The offense and how recently you were convicted will be evaluated in relation to the job for which you are applying.)
Yes No

If yes, give the date and explain fully below.



EDUCATION
Select the highest grade completed:

High School 1 2 3 4 5 6 7 8 9 10 11 12 GED

        College 1 2 3 4

 

Schools
Name and Location
Dates Attended
Course of Study
Degree/Diploma
High School
to
to
College or University
to
to
to
to
Graduate or Professional
to
to
Educational, Vocational Schools, Etc.
to
to
to
to
Child care training you have completed in the last three years (such as first aid, CPR, CDA, etc.):
References
List the names, addresses, and phone numbers of two people we may contact as references:
1)

2)


(List child care/early childhood experience first. Also include volunteer experience)
Current or Last Employer
Address
Job Title
Supervisor's Name
Employer Phone #
# You Supervised
Date Employed (mo/yr)
Starting Salary
$ per
Ending Salary
$ per
Reason for Leaving
May We Contact
Employer?
Yes No
Date Seperated (mo/yr)
Duties
Full Time
Years
Months
Part Time
Years
Months
If part time, number of hours per week


Current or Last Employer
Address
Job Title
Supervisor's Name
Employer Phone #
# You Supervised
Date Employed (mo/yr)
Starting Salary
$ per
Ending Salary
$ per
Reason for Leaving
May We Contact Employer?
Yes No
Date Seperated (mo/yr)
Duties
Full Time
Years
Months
Part Time
Years
Months
If part time, number of hours per week


Current or Last Employer
Address
Job Title
Supervisor's Name
Employer Phone #
# You Supervised
Date Employed (mo/yr)
Starting Salary
$ per
Ending Salary
$ per
Reason for Leaving
May We Contact Employer?
Yes No
Date Seperated (mo/yr)
Duties
Full Time
Years
Months
Part Time
Years
Months
If part time, number of hours per week


I certify that I have given true, accurate, and complete information on this form to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration, and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in this application and understand that false information of documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action, or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications.

Signature of Applicant Date: