Job Application

Name

Date

Address

City, State, and Zip Code

Home Phone Number

Work Phone Number

Position Applying For

Clinic Location Applying For Clinic Location Applying For Searcy Cabot Fort Smith Farmington/Fayetteville Springdale

Email Address

Minimum Salary Acceptable

Have you ever been involuntarily terminated from employment? Have you ever been involuntarily terminated from employment? Yes No

Have You Ever Been Employed By Kids Unlimited? Have You Ever Been Employed By Kids Unlimited? Yes No

If yes, please explain.

Can you, upon employment, provide genuine documentation establishing your identity & eligibility to be employed in the US? Can you, upon employment, provide genuine documentation establishing your identity & eligibility to be employed in the US? Yes No

Do you have any relatives or any other member of the same household employed by Kids Unlimited? Do you have any relatives or any other member of the same household employed by Kids Unlimited? Yes No

Primary Language

Other Languages Spoken

Are you fluent? Are you fluent? Yes No

Have you ever been convicted of a felony or misdemeanor including (sexual or child abuse) that has not been sealed, expunged or statutorily eradicated? Have you ever been convicted of a felony or misdemeanor including (sexual or child abuse) that has not been sealed, expunged or statutorily eradicated? Yes No

If you answered yes, please provide details of conviction, offense, location, date and sentence:

Has your professional license ever been revoked, suspended, limited or not renewed? Has your professional license ever been revoked, suspended, limited or not renewed? Yes No

Are any professional licensure actions now pending against you? Are any professional licensure actions now pending against you? Yes No

Do you have a high school diploma or G.E.D? Do you have a high school diploma or G.E.D? Yes No

EDUCATIONAL BACKGROUND | Name of School and Location

Degree of Area of Study

Date Enrolled

Date Graduated

Name of School and Location

Degree of Area of Study

Date Enrolled

Date Graduated

Name of School and Location

Degree of Area of Study

Date Enrolled

Date Graduated

List special awards or recognition

Briefly tell us why you are interested in the position you are applying for:

WORK EXPERIENCE: LIST CHRONOLOGICALLY STARTING WITH CURRENT POSITION (Past 6 years) | Employer 1 Name:

Date Hired:

Date Separated:

Street Address:

City & State:

Starting Wages:

Ending Wages:

Duties:

Phone Number:

Name/Title of Supervisor:

Reason for Leaving:

If current employer, may we contact? If current employer, may we contact? Yes No

If no, why?

Employer 2 Name:

Date Hired:

Date Separated:

Street Address:

City & State:

Starting Wages:

Ending Wages:

Duties:

Phone Number:

Name/Title of Supervisor:

Reason for Leaving:

If current employer, may we contact? If current employer, may we contact? Yes No

If no, why?

Employer 3 Name:

Date Hired:

Date Separated:

Street Address:

City & State:

Starting Wages:

Ending Wages:

Duties:

Phone Number:

Name/Title of Supervisor:

Reason for Leaving:

If current employer, may we contact? If current employer, may we contact? Yes No

If no, why?

FOR LICENSED CLINICAL AND MEDICAL PERSONNEL ONLY | License Number:

Effective Date:

End Date:

Have you ever been sanctioned, disciplined, or otherwise, reprimanded by a state board or any other governing body? Have you ever been sanctioned, disciplined, or otherwise, reprimanded by a state board or any other governing body? Yes No

If yes, please explain:

PROFESSIONAL REFERENCES | Name:

Area of Speciality:

Street Address:

City & State:

Phone Number:

Name:

Area of Speciality:

Street Address:

City & State:

Phone Number:

Name:

Area of Speciality:

Street Address:

City & State:

Phone Number:

I certify that all information I have provided herein; i.e., application, résumé, interview: is true and correct and that I have made no effort to conceal pertinent information. I authorize my former employers, schools and references to provide any information they may have regarding me, whether or not it is in their records. I hereby release them and their company from all liability for divulging same. I understand that all statements made are open to investigation by Kids Unlimited Learning Academy, and if hired, if any information given by me in this application or résumé is found to be false or misleading, I will be subject to dismissal at any time during the period of employment and I agree to hold Kids Unlimited Learning Academy and persons named herein blameless in that event.

I give permission to Kids Unlimited Learning Academy to administer any required background checks to complete the application process. If hired, I understand I will be subjected to drug tested upon hire and randomly thereafter.

If employment is obtained under this application, I will comply with all the rules and regulations of the company. I agree to be responsible for Company property and equipment issued me by the Company until returned by me and to pay for property and equipment not returned. Further, I understand and agree that my employment is for no definite period of time and may, regardless of date of payment of my salary, be terminated at any time by Kids Unlimited Learning Academy. I further understand that no representative of the company has authority to make any agreement contrary to the forgoing except the Chief Executive Officer of Kids Unlimited Learning Academy and any such agreement must be in writing and signed by the Chief Executive Officer and applicant/employee. As a condition of my employment, I agree to arbitrate all disputes arising in connection with this employment relationship pursuant to the Federal Arbitration Act.

I agree that all company policy and procedure, forms, electronic forms and software to which I gain access are the confidential trade secrets of Kids Unlimited Learning Academy. I further understand that as a condition of employment, I may be required to sign a confidentiality agreement protecting this property of Kids Unlimited Learning Academy.

Applicant's Signature:

Date:

EMPLOYMENT REFERENCE RELEASE | I hereby authorize Kids Unlimited Learning Academy to contact my former employers to obtain information concerning my employment and the reason for my termination of employment. I authorize my former employers to release and disclose to Kids Unlimited Learning Academy any information pertaining to my employment and termination of employment. I hereby release Kids Unlimited Learning Academy and my former employers from any and all damages, liabilities and claims that may result from the release and disclosure of such information.

Applicant's Signature:

Date: