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Employment Information
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First Name
*
Middle Name
Last Name
*
Maiden Name
Address
*
Email
Primary Phone
*
Cell Phone
Soc Security #
Educational Background:
High School
Graduated
Yes
No
Year Graduated
College
Graduated?
Yes
No
Year Graduated
Credentials
First Aid
CPR
20 Hr.
10 Hr.
10 Hr. Bos
5 Hr.
online Literacy
Director's Credential
VPK Standards
Check all areas in which you have proof of completion, that is CURRENT:
Expiration Dates:
First Aid
CPR
CDA
Director's Credential
Employment History:
1. Employer
Supervisor:
Phone:
Address:
Employed From:
Employed to:
May we Contact?
Yes
No
Duties:
Reason for leaving:
2. Employer
Supervisor:
Phone:
Address:
Employed From:
Employed to:
May we Contact?
Yes
No
Reason for leaving:
3. Employer
Supervisor:
Phone:
Address:
Employed From:
Employed to:
May we Contact?
Yes
No
Duties:
Reason for leaving:
Emergency Contact:
Phone
If you have worked in a child care facility that has had a license denied, revoked, or suspended in any state or jurisdiction or has been the subject of a disciplinary action or been fined while employed at the child care facility. Please Explain:
Today's Date
Signature
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I realize that this information is required for child care personnel according to Florida Statutes 402.3055 (b). I attest that this information is true to the best of my knowledge if requested under penalty of perjury.
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