Heartfelt Impressions Employment questionnaire Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. What is your street address? Question Title * 4. In what city do you live? Question Title * 5. In what state or U.S. territory do you live? Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Question Title * 6. What is your zip code? Question Title * 7. Home phone number Question Title * 8. Cell phone number Question Title * 9. At what email address would you like to be contacted? Question Title * 10. Are you 18 years of age or older? Question Title * 11. Person(s) to notify in case of emergency: name, phone number, address. Question Title * 12. How did you hear about Heartfelt Impressions? Question Title * 13. What position are you applying for? Question Title * 14. What are your expectations with regard to compensation? (include your expectations regarding all of the following: salary, vision, dental, health care, retirement, child care discount, paid time off) Question Title * 15. What is the date you are available to start? Question Title * 16. Are you interested in full or part time (define number of hours that feels reasonable to you)? Question Title * 17. What is your availability (are there any other time commitments you have between the hours of 6am-6:30pm Mon-Fri) Question Title * 18. Tell us about your professional work with young children? Question Title * 19. Do you have an age (be specific) you prefer to work with? Question Title * 20. Are there any age groups you are NOT comfortable working with? Question Title * 21. What are your short and long term professional goals? (How many years do you plan to work here?) Question Title * 22. Give 3 words you would use to describe yourself? Question Title * 23. Describe your understanding of Developmentally Appropriate Practices in a preschool setting? Question Title * 24. Do you have any physical, mental or medical impairment or disability that would limit your job performance in the position for which you are applying? If so, please explain Question Title * 25. Tell us about your education. High School Did you earn a diploma or GED? Address College Highest level completed? Address Major field of study Minor field of study Question Title * 26. Special Training or job related training you have received? Question Title * 27. Have you ever been convicted of a felony? If yes, please explain Question Title * 28. Employment History Company name Address City, State, Zip Phone Supervisor Supervisor's email Dates worked Most recent position Duties Salary Reason for leaving Question Title * 29. Employment History Company name Address City, State, Zip Phone Supervisor Supervisor's email Dates worked Most recent position Duties Salary Reason for leaving Question Title * 30. Employment History Company name Address City, State, Zip Phone Supervisor Supervisor's email Dates worked Most recent position Duties Salary Reason for leaving Question Title * 31. Please provide 3 professional references who are not related and are not previous employers Name Relationship to this person Address Phone# Email Name Relationship to this person Address Phone# Email Name Relationship to this person Address Phone# Email Question Title * 32. My typed name below is to serve as an electronic signature. I verify that everything on this application is true and complete to the best of my knowledge. Done