Application for Employment

In order to safeguard the well being of the youth we serve, the Club will investigate the accuracy of data provided in the application process for all applicants before appointment to the staff can be made. This investigation may include, but is not limited to: reference checks with past employers, military, schools, volunteer agencies, and police or other government or background check agencies.

POSITION APPLIED FOR

Which position are you seeking: ____________________________________________

Paid full-time ____________ Salary Required:______________

Paid part-time __________

Volunteer ______________ Date Available:________________

If Part-time or Volunteer: (Days and Time Available to work)

GENERAL APPLICANT INFORMATION

NAME:_______________________________ TELEPHONE:_______________

All other names known by:

ADDRESS:_____________________________________________________________________________

Previous Addresses: (Past 5 years) How Long at this address?

1)__________________________________________ ____________________

2)__________________________________________ ____________________

3)__________________________________________ ____________________

US CITIZEN? _____________ If not, VISA TYPE:_______________

Military Service? From_________ To __________ Which Branch? _________________

Discharge was voluntary/involuntary? __________________________________________

If involuntary, please describe circumstance________________________________________________________

WORK EXPERIENCE

Show present employer first and work back. Do not have to detail if resume is attached.

COMPANY NAME __________________________________ YOUR TITLE________________________________

COMPANY ADDRESS_____________________________________________________________________

DATE STARTED____________ DATE LEFT ___________ STARTING PAY_____________

LAST PAY____________

SUPERVISOR’S NAME ________________________________ TITLE _____________________

TELEPHONE__________________________

DESCRIPTION OF DUTIES AND RESPONSIBILITIES:

______________________________________________________________________________________________________

REASON FOR LEAVING:________________________________________________________________________

___________________________________________________________________________________________

COMPANY NAME __________________________________ YOUR TITLE_________________________

COMPANY ADDRESS________________________________________________________________

DATE STARTED____________ DATE LEFT ___________ STARTING PAY_____________

LAST PAY____________

SUPERVISOR’S NAME ________________________________ TITLE ___________________

TELEPHONE__________________________

DESCRIPTION OF DUTIES AND RESPONSIBILITIES:

______________________________________________________________________________________________________

REASON FOR LEAVING:________________________________________________________________________

___________________________________________________________________________________________

COMPANY NAME __________________________________ YOUR TITLE_____________________________

COMPANY ADDRESS_____________________________________________________________________

DATE STARTED____________ DATE LEFT ___________ STARTING PAY_____________

LAST PAY____________

SUPERVISOR’S NAME ________________________________ TITLE ____________________

TELEPHONE__________________________

DESCRIPTION OF DUTIES AND RESPONSIBILITIES:

______________________________________________________________________________________________________

REASON FOR LEAVING:________________________________________________________________________

___________________________________________________________________________________________

VOLUNTEER EXPERIENCE

AGENCY NAME____________________________________________ TELEPHONE________________________

COMPANY ADDRESS______________________________________________________________________________

SUPERVISOR’S NAME________________________________ TITLE_________________________

HOW LONG THERE?_____________

DESCRIPTION OF DUTIES AND RESPONSIBILITIES:

_____________________________________________________________________________________________________

EDUCATION

SCHOOL NAME & LOCATION MAJOR FROM / TO GRADUATED?

_________________________________________________________________________________________________

HIGH SCHOOL

________________________________________________________________________________________________

COLLEGE

_________________________________________________________________________________________________

OTHER

_________________________________________________________________________________________________

MILITARY

__________________________________________________________________________________________________

Professional Societies, Associations, Publications, Honors:

__________________________________________________________________________________________________

Any physical or mental conditions which may limit work performance? (specify)

__________________________________________________________________________________________________

Have you ever been convicted of a crime in the past ten years? If yes, describe.

__________________________________________________________________________________________________

Have you ever been criminally charged with any crime related to abuse/neglect or molestation of children? If yes, describe in full.

____________________________________________________________________________________________________

Do you have a valid drivers license? From which state?

_________________________________________________________________________________________________

How or by whom were you referred to the Boys & Girls Club?

_____________________________________________________________________________________________________

SKILLS AND INTERESTS

_____________________________________________________________________________________________________

IF ACCEPTED WHAT KIND OF ASSIGNMENT WOULD YOU PREFER?

_____________________________________________________________________________________________________

________________________________________________

CLERICAL APPLICANTS

TYPING WORDS/MINUTE ___________________________________________

OFFICE SOFTWARE PRODUCTS YOU ARE FAMILIAR WITH (Word, Excel, Power Point):

____________________________________________________________________________________________________

OFFICE MACHINES YOU CAN OPERATE

___________________________________________________________________________________________________

I certify that all the answers given by me to all the questions on this application and any attachment are to the best of my knowledge true and that I have not withheld any pertinent information.

I understand that any omission, misrepresentation or false information submitted in connection with this application may result in refusal of or summary dismissal from employment.

I hereby agree that in the course of considering my application, you may inquire to ascertain information concerning my background and I understand that, upon written request, information as to the nature and scope of the inquiry, if one is made, will be provided to me.

DATE SIGNATURE SOCIAL SECURITY NO.

___________________________________________________________________________________________________