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|APPLICANT INFORMATION |

| | |

|Applicant Name |Date of Birth |

| | | |

|Today's Date |Date Available |SS# |

| | | |

|Street Address |City |State |

| | | |

|Zip |Phone |E-mail |

| |

|Position Applied For: Assistant Teacher Teacher Kitchen Aid |

| |

|Full Time Part Time Either |

| | |

|Have you ever worked for this company? Yes No |If yes, when? |

| | |

|Have you ever been convicted of a felony? Yes No |If yes, explain |

| | |

|Are you a citizen of the United States? Yes No |If no, are you authorized to work in the U.S.? Yes No |

|REFERENCES |

|Full Name: |Relationship: |

|Address |

|Company: |Phone: |

|Full Name: |Relationship: |

|Address |

|Company: |Phone: |

|Full Name: |Relationship: |

|Address |

|Company: |Phone: |

|EDUCATION |

|High School: |Year Graduated: |

|College: |Year Graduated: |Degree: |

|Teaching Certificate: Yes No |Early Childhood Background: Yes No |

|Training related to Early Childhood Education |

| |

|Registry level: |

|PREVIOUS EMPLOYMENT |

|Company: |Supervisor: |

|Address: |Phone: |

|Job Title: |Starting Wage: $ |Ending Wage: $ |

|Responsibilities: |

|Dates of Employment: |Reason for leaving: |

|May we contact this employer? Yes No |

|Company: |Supervisor: |

|Address: |Phone: |

|Job Title: |Starting Wage: $ |Ending Wage: $ |

|Responsibilities: |

|Dates of Employment: |Reason for leaving: |

|May we contact this employer? Yes No |

|Company: |Supervisor: |

|Address: |Phone: |

|Job Title: |Starting Wage: $ |Ending Wage: $ |

|Responsibilities: |

|Dates of Employment: |Reason for leaving: |

|May we contact this employer? Yes No |

I certify that I have not purposely withheld any information, and that my answers are true to the best

of my knowledge. I understand that false or misleading information on this application, or in my interview, may result in immediate termination.

I permit Children’s Treehouse Child Care & Preschool of Holmen, LLC to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.

Please attach your transcripts.

Signature:

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Email Application to

daisha.rand@ or mail to

124 Hale Dr. Holmen WI, 54636

For more information call:

(608) 526-5888

Please indicate the days and times you are available:

Monday Tuesday Wednesday Thursday Friday

_____________ _____________ _____________ _____________ _____________

Additional Information: __________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

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