May we contact your previous supervisor for a reference? YES
NO
Company: Phone: Address: Supervisor:
Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference? YES
NO
Company: Phone: Address: Supervisor:
3 Job Title: Starting Salary: $ Ending Salary: $
Responsibilities:
From: To: Reason for Leaving:
May we contact your previous supervisor for a reference? YES
NO
Training Are you willing to participate in annual training? YES
NO
Are you certified in Pediatric CPR and 1 st Aid? YES
NO
Have you attended a Recognizing and Reporting Child Abuse and Neglect class? YES
NO
Do you have a valid food handlers card? YES
NO
Are you enrolled in the Oregon Criminal History Registry? YES
NO
If you are enrolled, what is your Registry Number and expiration date?:
If hired, are you able to obtain the following requirements within the first 30 days? YES
NO
If hired, are you willing to compete a 40 hour class at home. On your own time? YES
NO
Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge and would like to be considered for a position at Byrd House Beginnings LLC. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. Signature: Date: