| Ladybird Academy

All information in this application must be truthful and correct. Falsification or misrepresentation on the application is cause for immediate dismissal

Position Applied For *

Management

Teacher

Assistant

Admin

Chef

Location *

User Information

First Name *

Middle Initial

Last Name *

Address

Address *

City *

State *

Zip *

Contact Information

Home Phone

Cell Phone

Email *

Are you at least 18 years of age? *

yes

Are you a citizen of the United States? *

yes

If no, are you authorized to work in the US?

N/A

yes

Education

Highschool

High School Name

City

State

From

Did you graduate?

N/A

Did not graduate

Graduated

Degree

College

College Name

City

State

From

Did you graduate?

N/A

Did not graduate

Graduated

Degree

Other

Name

City

State

From

Did you graduate?

N/A

Yes

Degree

Employment History

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for leaving

May we contact this employer?

N/A

yes

Company

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

Reason for leaving

May we contact this employer?

N/A

yes

References

Reference

Full Name

Company

Relationship

Phone

Reference

Full Name

Company

Relationship

Phone

Extra

Can we contact you while you are currently employed? *

yes

Have you ever held a child care license with the Department of Children & Families *

yes

If yes, please identify where and when license was held and what type of program the license was for

Are you registered to provide child care in your home? *

yes

While employed in a child care program, have you ever been the subject of disciplinary action? *

yes

Have you been the party responsible for a child care facility receiving an administrative fine? *

yes

If yes, please explain

Have you ever been convicted of or charged with a crime or felony? *

yes

If yes, please explain

Are you a member of a secret society? *

yes

Do you know anyone who is currently working for Ladybird Academy or who has previously worked at Ladybird Academy? *

yes

Other professional qualifications

What code is in the image? *

Enter the characters shown in the image.

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User Information

Address

Contact Information

Education

Employment History

References

Extra