APPLICATION FOR EMPLOYMENT (AN EQUAL OPPORTUNITY EMPLOYER)

PERSONAL INFORMATION DATE SOCIAL SECURITY

NAME NUMBER LAST FIRST MIDDLE

PRESENT ADDRESS STREET CITY STATE ZIP

ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED

IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? YES NO

EMPLOYMENT DESIRED DATE YOU SALARY

POSITION CAN START DESIRED IF SO MAY WE INQUIRE

ARE YOU EMPLOYED NOW? OF YOUR PRESENT EMPLOYER?

HAVE YOU EVER WORKED FOR YWCA BEFORE? WHEN?

REFERRED BY

EDUCATION NAME AND LOCATION OF SCHOOL DID YOU

GRADUATE? DEGREE SUBJECTS STUDIED

HIGH SCHOOL

COLLEGE

GRADUATE SCHOOL

TRADE, BUSINESS CORRESPONDENCE

SCHOOL

GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

ACTIVITIES: (CIVIC, ATHLETIC, ETC.) EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF ORIGIN OF ITS MEMBERS.

(CONTINUED ON OTHER SIDE)

PHONE NUMBER ARE YOU 18 YEARS OR OLDER? YES NO

EMPLOYMENT HISTORY (LIST YOUR LAST FOUR EMPLOYERS, STARTING WITH THE LAST ONE FIRST).

DATES EMPLOYEDMONTH AND YEAR

NAME AND ADDRESS OF EMPLOYER POSITION SUPERVISOR PHONE # REASON FOR

LEAVING

MAY WE CONTACT THESE EMPLOYERS? YES NO

WORK-RELATED REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU WHO HAVE KNOWLEDGE OF YOUR ABILITIES AND EXPERIENCE

NAME ADDRESS BUSINESS PHONE NUMBER

1.

2.

3.

MAY WE CALL THESE REFERENCES? YES NO

EMERGENCY CONTACT: NAME ADDRESS PHONE # RELATION

WHY ARE YOU APPLYING FOR THIS POSITION?

“I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE, AND I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO CONFORM TO THE COMPANY’S RULES AND REGULATIONS, AND I AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT EITHER MY OR THE COMPANY’S OPTION. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME BY THE COMPANY. I UNDERSTAND THAT NO COMPANY REPRESENTATIVE, OTHER THAN IT’S DIRECTOR, AND THEN ONLY WHEN IN WRITING AND SIGNED BY THE DIRECTOR HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIC PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING. I UNDERSTAND THAT A ROUTINE BACKGROUND CHECK WILL BE PERFORMED.”

SIGNATURE DATE

NAME AND LOCATION OF SCHOOLHIGH SCHOOL: DID YOU GRADUATEHIGH SCHOOL: DEGREEHIGH SCHOOL: SUBJECTS STUDIEDHIGH SCHOOL: NAME AND LOCATION OF SCHOOLCOLLEGE: DID YOU GRADUATECOLLEGE: DEGREECOLLEGE: SUBJECTS STUDIEDCOLLEGE: NAME AND LOCATION OF SCHOOLGRADUATE SCHOOL: DID YOU GRADUATEGRADUATE SCHOOL: DEGREEGRADUATE SCHOOL: SUBJECTS STUDIEDGRADUATE SCHOOL: NAME AND LOCATION OF SCHOOLTRADE BUSINESS CORRESPONDENCE SCHOOL: DID YOU GRADUATETRADE BUSINESS CORRESPONDENCE SCHOOL: DEGREETRADE BUSINESS CORRESPONDENCE SCHOOL: SUBJECTS STUDIEDTRADE BUSINESS CORRESPONDENCE SCHOOL: NAME AND ADDRESS OF EMPLOYERFROM TO: POSITIONFROM TO: SUPERVISORFROM TO: PHONE FROM TO: REASON FOR LEAVINGFROM TO: NAME AND ADDRESS OF EMPLOYERFROM TO_2: POSITIONFROM TO_2: SUPERVISORFROM TO_2: PHONE FROM TO_2: REASON FOR LEAVINGFROM TO_2: NAME AND ADDRESS OF EMPLOYERFROM TO_3: POSITIONFROM TO_3: SUPERVISORFROM TO_3: PHONE FROM TO_3: REASON FOR LEAVINGFROM TO_3: NAME AND ADDRESS OF EMPLOYERFROM TO_4: POSITIONFROM TO_4: SUPERVISORFROM TO_4: PHONE FROM TO_4: REASON FOR LEAVINGFROM TO_4: ADDRESS1: BUSINESS1: PHONE NUMBER1: ADDRESS2: BUSINESS2: PHONE NUMBER2: ADDRESS3: BUSINESS3: PHONE NUMBER3: WHY ARE YOU APPLYING FOR THIS POSITION: DATE: Last Name: First Name: Middle Name: Social Security: Date: Street: City: State: ZIP: Check Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffSalary Desired: Date You Can Start: Position: Are You Employed Now?: Present Employer?: Have You Worked for YWCA before?: When?: Referred By: Subjects of Special Study or Research Work: Special Skills: Activities: Check Box26: OffCheck Box27: OffReference Name1: Reference Name 2: Reference Name 3: Check Box31: OffCheck Box32: OffEmergency Contact Address: Emergency Contact Name: Phone Number: Emergency Contact Relation: Dates Employed Month and Year 1: Dates Employed Month and Year 2: Dates Employed Month and Year 3: Dates Employed Month and Year 4: Emergency Contact Phone Number: