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DESIRED LOCATION
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Central Bucks Area
(Doylestown, Chalfont,
Warrington)
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Montgomery County
(Ft. Washington, Dresher)
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Upper Bucks County
(Quakertown, Perkasie, Hilltown,
Silverdale, Blooming Glen)
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Montgomery County
(Indian Valley - Souderton,
Telford, Franconia, Harleysville)
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POSITIONS APPLYING FOR
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Preschool Fitness Coach
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Sports Coach
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Dance
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Cheerleading Coach
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PERSONAL INFORMATION
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Name (Last, First, Middle Initial)
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Address
(Street, City, State, Zip Code)
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Email Address
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Home Phone #
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Cell Phone #
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Are you at least 18 years of age?
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Have you ever been convicted of a felony or subjected to a deferred adjudication on a felony charge?
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yes no
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no yes If "Yes", please explain in detail in comments section below.
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EDUCATION Did you graduate from highschool or receive GED?
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yes no
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Names of College/University Dates Attended Type of Degree Major Actual or Expected Graduation
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#1
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#2
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#3
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REFERENCES List references who are NOT related to you and are NOT previous supervisors
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Name Type of Reference Telephone Email Address
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#1
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#2
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#3
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EMPLOYMENT HISTORY List starting with the present/most recent employer.
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Employer Address Supervisor Telephone
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#1
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Dates Employed (Mo/YR) Salary Position Duties
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Full-time Part-time, hrs/wk. May we contact for references? Reason for leaving
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YES NO
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Employer Address Supervisor Telephone
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#2
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Dates Employed (Mo/YR) Salary Position Duties
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Full-time Part-time, hrs/wk. May we contact for references? Reason for leaving
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YES NO
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Employer Address Supervisor Telephone
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#3
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Dates Employed (Mo/YR) Salary Position Duties
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Full-time Part-time, hrs/wk. May we contact for references? Reason for leaving
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YES NO
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PLEASE READ CAREFUL AND PROVIDE FIRST, MIDDLE, AND LAST NAME INITIALS
I certify that all the information provided by me in connection with my application, whether on this document or not, is true and complete, and I
understand that any misstatement, falsification, or omission of information may be grounds for refusal to authorize investigation of my previous
employers and my personal background and release all parties from all liability for any damage that may result in furnishing information to you.
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Applicants Initial:
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Date:
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Applicants Signature (signature required at interview date)
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Are you currently CPR certified? Are you curently 1st Aid Certified Had you had a TB test within the last year?
YES NO YES NO YES NO
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