Full Name *

Date of birth *

Email *

Phone *

Address *

Social Security No.

TX Driver's License No.

Did you graduate from high school or receive a GED?

Yes

If no, what was the highest year completed?

Have you attended college or a technical/vocational school?

Yes

Name of School:

Location:

Dates Attended (month/year):

From

To:

Field of Study:

Did you graduate:

Yes

If yes, provide the type of diploma, degree, or certification received:

Describe any other special training you have had which you feel is pertinent. Include continuing education units, dates, locations, and the name of the organization or agency that sponsored the training:

List any professional licenses, certifications or credentials you hold:

Please provide official transcripts from the above mentioned colleges or universities attended.

List all employement held within the past 10 years beginning with the current or last employer and include dates of employment:

Position

Employer

From (month/year):

To (month/year):

Describe the professional skills you posses that qualify you to work in a therapeutic school environment:

Describe any other experiences you have had which you feel is pertinent. Include volunteer work in the description, if applicable, and provide dates and locations:

Please provide professional references:

Name

Phone

Title

I certify that the information contains no willful misrepresentation of falsification and that it is true and complete to the best of my knowledge and belief. I hereby authorize It’s a Sensory World! to contact the persons listed on the form. I understand that It’s a Sensory World! may contact others and at any time seek verification of any and all information on this form. I understand that any willful misrepresentation is cause for immediate dismissal from the interview process. or later, termination.

Yes

Signature:

Date