Name_____________________________________ Date of birth:____/_____/_____ Sex: M or F

Last

First

DD

MM YYYY

Circle

Address: ______________________________________________________________________
Street address
Apartment/ Unit number
_______________________________________________________________________
City
State
Zip code
Phone number:_______________________________ Can you receive text messages? Yes or No
Email: ______________________________ Position applied for: ________________________
Are you a citizen of the United States?

Yes or No

If no, are you authorized to work?

Yes or No

Do you have a reliable method of transportation?

Yes or No

Are you comfortable with traveling to others homes?

Yes or No

Are you comfortable with others coming to your home?

Yes or No

Have you ever taught an instrument before?

Yes or No

Are you comfortable with children?

Yes or No

Travel radius: (Circle all that apply) 10 minutes

20 minutes 30 minutes

45 minutes

Skills and Experience: Please write the instrument(s) you can play and how long you have played them
Instrument___________________________Years____________ Willing to teach it? Yes or No
Instrument___________________________Years____________ Willing to teach it? Yes or No
Instrument___________________________Years____________ Willing to teach it? Yes or No
Disclaimer and Signature
Instrument___________________________Years____________ Willing to teach it? Yes or No
I certify that my answers are true and complete to the best of my knowledge. If this application
leads to employment, I understand that false or misleading information in my application or
interview may result in my release
Signature: _____________________________________ Date: __________________________