Employment Application for
BrainWorks Learning Center

Last name of applicant:

First name of applicant:

Primary Phone No. (xxx-xxx-xxxx):

Secondary Phone No. (xxx-xxx-xxxx):

Disclaimer: The following information is required in order to do background checks on all employees. The background check is required before you are cleared to go into the schools. If you are uncomfortable putting that information on line, simply fill in with zeros, and you may give it to us once you are hired.

Date of Birth (xx-xx-xxxx):

Are you a citizen of the US?:

If no, are you authorized to work in the US?:

Have you ever been convicted of a felony? (Criminal background checks will be performed):

If yes, please explain.:

Employment Preferences

Grade level desired:

Subject area desired:

Have you ever worked for this company before?:

At which school would you prefer to work?:

How far would you be willing to drive for a position?:

Are you available from 2pm to 6pm in the afternoons?:

Are you available now to work?:

Are you fluent in any languages besides English?:

If "other" is checked, please list what other languages.:

Do you have a Teacher Certification? (This is not required.):

If yes, please list the area(s) of certification:

Please list two professional references:

Relationship to applicant:

Phone no. (xxx-xxx-xxxx):

Address (Street or email):

Relationship to applicant:

Phone no. (xxx-xxx-xxxx):

Address (Street or email):

Relationship to applicant:

Phone no. (xxx-xxx-xxxx):

Employment History: Please list your last 2 places of employment, beginning with most recent job first.

Please answer the following questions in complete sentences.

Do you have a personal computer and internet access at home?:

Which computer programs are you familiar with and use on a daily basis?:

Describe your organizational skills and teaching style.:

Do you have any medical conditions?:

Are you able to lift and carry at least 30 pounds?:

Please list five adjectives to describe yourself and explain why you chose those.:

Date (Enter as 00/00/0000):

Disclaimer and Signature:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to my employment, I understand that false or misleading information in my application or interview may result in my release.

Form: Job Application