EMPLOYMENT APPLICATION

PERSONAL INFORMATION

LAST NAME:

 

FIRST NAME:

 

MIDDLE NAME:

 

SOCIAL SECURITY NUMBER:

 

ADDRESS:

 

CITY:

 

ZIP:

 

TELEPHONE:

 

ARE YOU 18 OR OLDER?:

Yes

No

IF NOT WHAT IS YOUR AGE?:

 

AVAILABILITY

TOTAL HOURS AVAILABLE PER WEEK:

 

ARE YOU LEGALLY ABLE TO BE EMPLOYED IN THE UNITED STATES?:

Yes

No

SCHOOL MOST RECENTLY ATTENDED

SCHOOL NAME:

 

LOCATION:

 

PHONE NUMBER:

 

TEACHER OR COUNSELOR:

 

LAST GRADE COMPLETED:

 

GPA:

 

DID YOU GRADUATE?:

Yes

No

ARE YOU NOW ENROLLED?:

Yes

No

LIST YOUR SPORTS OR ACTIVITIES:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPINGSPEED:

RECEPTIONIST

MAINTENANCE   

BOOKKEEPING   

FITNESS 

JANITORIAL

REFEREE

SCOREKEEPING

AQUATICS

HOUSEKEEPING

GROUNDS KEEPER

CHILDCARE  

LIST ANY SPECIAL QUALIFICATIONS THAT YOU FEEL MAY QUALIFY YOU FOR EMPLOYMENT:

 

 

 

 

 

TWO MOST RECENT JOBS

(If not applicable, list U.S. military, work performed on a voluntary basis or personal references)

JOB 1

 

 

EMPLOYER:

 

LOCATION:

 

DATES WORKED:

FROM:

TO:

PHONE NUMBER:

 

SUPERVISOR:

 

SALARY:

 

REASON FOR LEAVING:

 

JOB 2

 

 

EMPLOYER:

 

LOCATION:

 

DATES WORKED:

FROM:

TO:

PHONE NUMBER:

 

SUPERVISOR:

 

SALARY:

 

REASON FOR LEAVING:

 

Any health problems or physical disabilities which could affect your employment?

Yes

No

Do you now have or have you had, within the last six months, any contagious or communicable diseases?

Yes

No

During the past ten (10) years, have you ever been convicted of a crime, excluding misdemeanors and traffic violations?

Yes

No

*A conviction will not necessarily bar you from employment.

  1. I certify that the information contained on this application is correct to the best of my knowledge and understand that deliberate falsification of this information is grounds for dismissal.
  2. I authorize the references listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.
  3. I acknowledge that, if I become employed, I will be free to terminate my employment at any time for any reason and the Eden YMCA retains the same rights. No representative of the Eden YMCA has the authority to make any contrary agreement.

                                                 
(signature)

                                                 
(date-MM/DD/YY)

Website Copy