Application Form

Position: Canvasser □ Vendor Fair Rep □ Site Coordinator □

Please enter the following information:

First Name:

Last Name:

Sex:

Street Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Other Phone:

Fax Number:

Email Address:

References

Please list three character references/tutoring references, other than family members.
Please include area code with all phone numbers.

1. Name: Relationship: Phone Number: # of years:?

1
 Email:

2. Name: Relationship: Phone Number: # of years:?

Email:

3. Name: Relationship: Phone Number: # of years:?

Email:

Emergency Contact

Please provide a contact in case of an emergency:

Name Address Phone Number Relationship

Do you have a valid Fingerprint Clearance Card? (yes/no)

Have you ever been arrested or convicted of a felony? (yes/no)

By completing this form and signing in the space below, you are attesting that the above information is true to the best of your
knowledge. You also give Sure Prep Learning, LLC permission to run a national background check on you for internal use only.

Signature _________________________________________

Full Name _________________________________________

Date ______________________

Sure Prep Learning, LLC attests that the information submitted on this application will be for private internal use only and that by
receiving this application, it is not a guarantee of employment.