Last Name:
First Name:
Home Phone:
Cell Phone:
E-Mail:
Mailing Address:
Apt, PO Box, etc.:
City:
State:
Zip:
Position Desired:
Salary Expected:
Weekly Availability:
Date Available to Work:
Highest Level of Education Completed:
Any Special Certification?:
Do you have a Driver License? Yes No
Number:
CPS will require a DMV Driving Record
Are you authorized to work in the United States? Yes No
Have you served in the Armed Forces? Yes No
If so, which branch?
Do you have any chronic illnesses of which we should be aware?
Name: Phone #: Relationship:
Please Read Carefully
Applicant's Certification and Agreement
By submitting this application I hereby certify that the facts set forth in the above Employment Application are true and complete to the best of my knowledge. I understand that if employed, falsified statements on this application shall be considered cause for dismissal. I agree that, should less than two weeks notice be given before quitting, up to one week of salary may be withheld by CPS to pay for the costs of replacement.
