Education  (Please complete all information that applies)

 

Name of School     City/State        Major Course           Scholastic     Highest       Degree/

                                                      or Subject                Average        Grade         Diploma

                                                                                                        Completed

 

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High School

 

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College  *(College grads. may be required to submit transcript upon hire)

 

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Graduate Work

 

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Other

 

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Professional Organizations: Do not list any organization that would reveal race, creed, religion, national origin, physical handicap, marital status, or ancestry.

 

__________________________________________________________________________

 

__________________________________________________________________________

 

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Professional Licenses/Certifications  State of Issue   Number Date Issued    Renewal Date

 

1.  Have you successfully completed the February 1993 Revised D.D.A. Medication Administration Training Program Curriculum?  (    ) Yes    (    ) No

 

2.  Has your privilege to administer medication in a D.D.A. community provider agency ever been revoked and/or terminated?  (    ) Yes    (    ) No

 

If yes, When (date) _______________; Where (agency) ____________________________; Delegating R.N. __________________; Reason __________________________________.

 

I, _________________________, authorize Flying Colors of Success, Inc. to obtain information from ___________________________ concerning my medication administration status.

                   (previous employer/agency)

 

3.  Do you have a valid Driver's license?   (    ) Yes   (    ) No

 

__________________________________________________________________________

State       License No.                   Expiration date        Restrictions            No. of points

 

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Have you ever been convicted of any crime other than minor traffic

violations?       (    ) Yes   (    ) No

Have you ever been convicted of driving under the influence of alcohol/drugs?       (    ) Yes   (    ) No

Do you have any convictions regarding the use, possession or sale of alcohol/drugs?   (    ) Yes   (    ) No

If yes, attach a full explanation of the circumstances.  Please note that a conviction record will not necessarily prevent employment at Flying Colors of Success, Inc.  Such factors as nature of offense and other aggravating and mitigating circumstances may be considered.

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