Employment Form EMPLOYMENT APPLICATION Employer: Apple Pie Day Care Address: 3 South State Road City/State/Zip: Upper Darby, Pennsylvania 19082 (610) Telephone: 352-1064 It is the policy of Apple Pie Day Care to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability or veteran status.Applicant Name* Address* Street Address City State / Province / Region ZIP / Postal Code Number of years at this address* Email Address* Daytime Phone* Evening Phone* Job Position Applied For:* Salary Desired* Have you applied to Apple Pie previously?* Yes No When did you apply before? (Approximate month & year)* Are you at least 18 years old?* Yes No If you are offered employment, when would you be available to begin work?* Are you legally eligible for employment in the United States?* Yes No Have you ever been convicted of any crime, including traffic violations?* Yes No Please provide details about your convinction(s) THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT UNLESS RELEVANT TO THE TYPE OF EMPLOYMENT.Applicant Employment HistoryList your current or most recent employment firstEmployer Name Address City/State/Zip Job DutiesReason for LeavingDates of Employment (Month/Year) Employer Name Address City/State/Zip Job DutiesReason for LeavingDates of Employment (Month/Year) Employer Name Address City/State/Zip Job DutiesReason for LeavingDates of Employment (Month/Year) Applicant's Education and TrainingList your education and training.High School Name and Address* Last Grade?* 9 10 11 12 Diploma?* Yes No College Name and Address* Did you receive a degree?* Yes No If yes, degree received Other Training (graduate, technical, vocational)Awards, Honors, Special AchievementsApplicant's Skills List any skills that may be useful for the job you are seeking. Enter the number of years of experience, and circle the number which corresponds to your ability for each particular skill. (One represents poor ability, while five represents exceptional ability.)Applicant's SkillsAbility or SkillYears of experienceRate 1-5 ReferencesList any two people who would be willing to provide a reference for you.Name* Address* City/State/Zip* Telephone* Relationship* Name* Address* City/State/Zip* Telephone* Relationship* Please provide any other information that you believe should be consideredCERTIFICATION I certify that the information provided on this Application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my Application, or if employment commences immediate termination. I authorize Apple Pie Day Care to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education. I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS. APPLICANT SIGNATURE*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.