Give Me A Break, Inc - Providing Qualified, Experienced, and Dedicated pre-screened child care professionals to Southwest Florida.

Employment Application

If you are interested in a position working through Give Me A Break Inc., please fill out the application below completely and click on the Submit button to send us your information. Thank you!

APPLICANT INFORMATION
First Name:	M.I.
Last Name:
Street Address:
City:
State/Zip:
Phone:
Email:
Date Available:
Desired Salary:
Position Applying For:
Are you a US Citizen?:	YES NO
If no, are you authorized to work in the US?:	YES NO	If so, when?
Have you ever worked for this company?:	YES NO
Have you ever been convicted of a felony?:	YES NO	If yes, please explain?
EDUCATION
High School:
Address:
Dates:	From To
Did you graduate?:	YES NO	Degree:

College:
Address:
Dates:	From To
Did you graduate?:	YES NO	Degree:

Other:
Address:
Dates:	From To
Did you graduate?:	YES NO	Degree:
REFERENCES
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:

Full Name:
Relationship:
Company:
Phone:
Address:

Full Name:
Relationship:
Company:
Phone:
Address:
PREVIOUS EMPLOYMENT
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Dates Employed:	From To
Reason For Leaving:
May we contact your previous supervisor for a reference?:	YES NO

Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Dates Employed:	From To
Reason For Leaving:
May we contact your previous supervisor for a reference?:	YES NO

Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
Ending Salary:
Responsibilities:
Dates Employed:	From To
Reason For Leaving:
May we contact your previous supervisor for a reference?:	YES NO
MILITARY SERVICE
Branch:
Dates Served:	From To
Rank at Discharge:
Type of Discharge:
If other than honorable, please explain:
DISCLAIMER AND SIGNATURE
By checking the box below and filling out your name and date, you certify that all your answers are true and complete to the best of your knowledge.
Yes, I certify that my answers are true to the best of my knowledge.
Name: Date:

Additional Comments:

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