NAME____________________________ SOCIAL SEC #_________________________

ADDRESS_________________________ PHONE #____________________

TODAYS DATE__________ NAME OF SCHOOL ATTENDING__________________

DO YOU HAVE A VALID MINNESOTA DRIVERS LICENSE? _______________

HAVE YOU HAD ANY TICKETS OR ACCIDENTS? _________________

PREVIOUS EMPLOYMENT

PLEASE LIST LAST 2 EMPLOYERS FOR REFERENCES

LAST RECENT EMPLOYER______________________________________________________________

SUPERVISOR’S NAME__________________________ PHONE____________________

DATES OF EMPLOYMENT - FROM___________________ TO ____________________________

REASON FOR LEAVING_________________________________________________________________

LAST RECENT EMPLOYER______________________________________________________________

SUPERVISOR’S NAME__________________________ PHONE____________________

DATES OF EMPLOYMENT - FROM___________________ TO ____________________________

REASON FOR LEAVING_________________________________________________________________

DO YOU HAVE ANY MEDICAL CONDITIONS THAT WOULD KEEP YOU FROM

PERFORMING ANY JOB AT THE NURSERY? (ie. Lifting or being on your feet, etc.)

______________________________________________________________________________

PLEASE STATE THE TIMES YOU WOULD BE AVAILABLE TO WORK ON THE FOLLOWING DAYS:

MON.____________ TUE.____________ WED.____________ THUR._____________

FRI.____________ SAT.____________ SUN.____________

NURSERY HOURS ARE: MON-FRI 9AM-8PM SAT 9AM-6PM SUN 9AM-5PM

(These are our peak season hours. Hours will vary during the season.)

IN CASE OF A MEDICAL EMERGENCY PLEASE CONTACT:\

NAME_________________________ PHONE_____________________

I declare the above information is complete and true, and that misinformation would be cause for dismissal.

APPLICANTS SIGNATURE____________________________________ DATE___________________

FOR OFFICE USE ONLY: DATE HIRED___________ SALARY________