Today's Date:	mm/dd/yy
Full Name:
	Last Name, First Name M.I.
Address1:
City:
State:		Zip Code:
Phone:
Email:
Soc. Sec No:		Date Available:	mm/dd/yy
Desired Position:	Tutor Mentor Teacher Liaison Parent Assistant
Are you a US citizen? Yes No
If no, are you authorized to work in the U.S.? Yes No
How did you find out about this position?
Have you ever worked for our company? Yes No
If so, when:
Have you ever been convicted of a felony? Yes No
If so, explain:
EDUCATION
High School:
Address:
	From: mm/yy To: mm/yy
College:
Address:
	From: mm/yy To: mm/yy
Degree:
Other:
Address:
	From: mm/yy To: mm/yy
Degree:
GENERAL
Subject of special or research work:
Special Training:
Special Skills:
Languages:
REFERENCES
Full Name:		Relationship
Company		Phone No.
Full Name:		Relationship
Company		Phone No.
Full Name:		Relationship
Company		Phone No.
DISCLAIMER
By submitting this form, I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed; falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant Federal and State Laws.