Gram's Place, Inc.Application for Employment

(Please Print or Type)Date ---------------Name -------------------Address -------------------------

SSN ---------------Daytime Phone No. _EvemngPhoneNoo _

Position Requested _Full or Part Time ----------------------

Salary Requested _

Education:

SchoolDates

Attended

High School

College

Graduate School

Trade School. - .

E"Xp~rience:

Employer and AddressDates

Employed Position

GraduatedYIN

DegreeEarned Q.P.A.

SalaryReason

Left

1) _

2) _

3) __ ------ _

4) _

(use additional paper if necessary)

Yes No

-2-

Have you ever been convicted of a crime?If yes, explain -------------------------

Have you ever been investigated fOTchild abuse or molestation?

Have you ever had CPR training?If yes, date of current certification _

Have you ever had First Aid training?If yes, date of current certification _

Please provide two professional references:

Name Company Phone No.

1) _

2) _

Please provide two personal references(not related to you)

Name Phone No.

1) _

2)