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Harvest Hills Day Care Application         Page2   

References      Below list three persons not related to you, whom you have known at least one year.
Name Address  Business  Yrs.Acquainted
       
       
       

   Service Record

Branch of the Service Discharge Date:
 Have you ever been convicted of a Felony?  p Yes p No     

  Why are you interested in child care?

______________________________________________________________________________________

    Authorization

 " I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified information on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

 Date______/____/_____ Signature___________________________________

Mail to: Harvest Hills Day Care /  Attn: Gloria. Levenseller  / PO Box 3128 / Auburn, ME 04212     - OR -

Call for FAX number

 

   Thank You for applying.

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