We are an equal opportunity employer. It is the strict policy of this organization not to discriminate on the basis o race, sex, religion, national origin, marital status, age, weight, height, color or handicap in the hiring, promotion, payment or discipline of employee.

We will not discriminate against a person with a covered disability under the mericans with Disabilities Act in regard to employment practices, or terms, conditions and privileges of employment

Name Date

Address

Are you over 18? Yes No

In case of emergency, who should we notify?

Phone Number

Employment Desired

Position

Date Available

Salary Desired

What prompted your application with us?

Education

Would you be willing to continue your education by enrolling in courses or other training programs that may be recommended?

Please list any courses, volunteer work, hobbies or interests that would relate to the position you are applying for:

I hereby give you my permission to contact the below employers, references and educational institutions to verify the items I listed below. I hereby release Bemis Farms Preschool and Day Care and the below referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the information to you. I express and fully waive all written notice from all prior employers. I also understand that because of the nature of my job and lcensing requirements, I hereby consent to the release of this application or portions of this application to representatives of Department of Consumer and Industry Services or other governmental agencies.

I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers and hereby release my former employers from all claims, liability and damages that may result from furnishing the information to you.

Former Employers