General Information

General Information
Emergency Contact
Other Background


High School
Graduate School
Other Education

Employment Experience

Employer #1
Employer #2
Employer #3
Employer #4



Additional Information

Additional Information


Reference #1
Reference #2
Reference #3
Reference #4
Read Carefully and Sign

I hereby authorize Ebenezer Child Care Centers, Inc. to investigate my background, and verify all information which I provided in this application or otherwise. I release Ebenezer and its subsidiaries from any liability arising out of their investigation of my application for employment. I further authorize my past employers to share with Ebenezer any information concerning my employment that may be relevant to making an employ- ment decision, and release all parties from any liability for damage that may result from furnishing this information. I certify that this information and any supporting documents that I have provided or will provide to Ebenezer, whether oral or written, is correct to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of fact will constitute grounds for the rejection of my application, withdrawal of an offer of employment, or immediate dismissal from employment with Ebenezer regardless of when the falsification is discovered.

I have read and understand each of the statements above, and sign this form in return for consideration for employment in the job specified.