Name: __________________________________________________
Today’s Date: _____________________________________________
Phone number with area code: __________________________________
Alternate Phone Number: _____________________________________
Address: _________________________________________________
Age: _______ Date of Birth: ___________________________________
Email-address: _____________________________________________

All positions are part time and you must be flexible meaning, willing to work 1st and 2nd shifts when needed. This is just a brief interview. It'll be more in detail if you are called in for a face to face interview, which is set up before you are actually hired. You must have a high school diploma or a GED and have it on hand to show at time of interview. You must be at least 18 years or older to work here. We are also looking for on call and substitute providers.

1. Have you ever work with children before?
If so, where? __________________________________________________________________
for how long?__________________________________________________________________
What were your job duties? ________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

2. Are you flexible during the day and after 6pm and willing to work a rotating shift?
Between day and evening shift: Yes No

3. Do you have any type of criminal background? (even if it was dismissed, I
need to know now cause it will show up and/or I'll be informed ) If so please explain:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

4. Are you currently employed? Yes No
if so, where and what time do you work there? ___________________________________________
____________________________________________________________________________

5. Are you currently CPR and/ or First Aid trained and have your updated card to show
it? Yes No

6. How much per hour are you expecting to be paid? _______________________________________
7. How many hours are you looking for? ________________________________________________

8. Do you have your own transportation?(not the city bus it doesn’t run here.) Yes No

9. Where was the last job you had? ___________________________________________________
- How long were you there? ________________________________________________________
- Who was your supervisor? ________________________________________________________

- What was your reason for leaving? __________________________________________________
____________________________________________________________________________
____________________________________________________________________________

10. How many times during that time frame, for whatever reason, did you have to call in?
____________________________________________________________________________

11. Do you have computer skills yes or no. ________

Can you type yes or no?If yes about how many words per minute? ____________________________

What computer programs are you familiar with ____________________________________________________________________________
____________________________________________________________________________

How is your grammar? ____________________________________________________________________________

12. What part of town do you live on? Check by the area in which you live.
___ Madison St.
___ Sango
___ Ft. Campbell close to post
___ On APSU campus
___ St. Bethelem
___ Near APSU
___ New Providence
___ Riverside Drive
___ Oak Grove
___ other area, where? ____________________________________________________________________________

Please provide me with 3 people you have worked for, (NOT with) that can verify your work history. Their name, phone number, their position, and the time frame you worked for them, along with the best time to contact them. You may need to use a separate sheet of paper. You may email it to: Doris@cierasdaycare.com or fax it to me at 931-645-4657. Call first to let us know you are faxing us an application or mail it to 368 Hilltop Drive Clarksville, TN 37040.
Signature ________________________________________ Date: ________________________

Address:
Ciera’s Loving Touch Home Childcare
368 Hilltop Drive
Clarksville, TN 37040

Email - Doris@cierasdaycare.com or Fax- 931-645-4657 call before faxing.