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Employment Information
Indicate last 3 Employers, Dates, Salary, Duties
(Beginning with most current.)
Name: _______________________________________________________________________________
Address: ______________________________ City: ________________ State: ________ Zip: ________
Phone: ___________________________ Supervisor’s Name: ___________________________________
Date of Employment: (Beginning) _________________________ (Ending) ________________________
Position / Job Title: ____________________________________________________________________
Reason for leaving: _____________________________________________________________________
Name: _______________________________________________________________________________
Address: ______________________________ City: ________________ State: ________ Zip: ________
Phone: ___________________________ Supervisor’s Name: ___________________________________
Date of Employment: (Beginning) _________________________ (Ending) ________________________
Position / Job Title: ____________________________________________________________________
Reason for leaving: _____________________________________________________________________
Name: _______________________________________________________________________________
Address: ______________________________ City: ________________ State: ________ Zip: ________
Phone: ___________________________ Supervisor’s Name: ___________________________________
Date of Employment: (Beginning) _________________________ (Ending) ________________________
Position / Job Title: ____________________________________________________________________
Reason for leaving: _____________________________________________________________________
Physical Record
How would you describe your general health? ___________________________________
Are there any physical or personal limitations on the type of work you can do with children at school or
the amount of time you can spend at work? [ ] No [ ] Yes
If Yes, please explain _______________________________________________________
Date of last physical exam: ______________________________
Are you able to lift 50 lbs. without assistance? [ ] Yes [ ] No
Have you had a TB test within the past year? [ ] Yes [ ] No