Apply Today to Make a Difference Step 1 of 7 14% FacebookThis field is for validation purposes and should be left unchanged.APPLICANT INFORMATIONLast Name(Required)First(Required)M.I.(Required)Date(Required) MM slash DD slash YYYY Street Address(Required)Apartment/Unit #(Required)City(Required)State(Required)ZIP(Required)Phone(Required)E-mail Address(Required) Date of Birth(Required) MM slash DD slash YYYY Social Security Number(Required)Position Applied for(Required)Date available(Required) MM slash DD slash YYYY Hours Available(Required)Have you used a different name in the past?(Required)If so what?Have you ever applied here before?(Required) Yes No If so when?Have you ever worked for this company?(Required) Yes No If so when?Have you ever been convicted of a felony?(Required) Yes No If yes, explain? EDUCATIONHigh School(Required)Address(Required)From(Required)To(Required)Did you graduate?(Required) Yes No If not, do you have a GED?College(Required)Address(Required)From(Required)To(Required)Did you graduate?(Required) Yes No DegreeOtherAddressFrom(Required)To(Required)Did you graduate?(Required) Yes No Degree(Required) SKILLS AND INTERESTWhat hobbies, interest, and activities do you enjoy?(Required)What certifications/trainings do you have?(Required) REFERENCESPlease begin with most recentFull name(Required)Relationship(Required)CompanyPhone(Required)Address(Required)Full name(Required)Relationship(Required)Company(Required)Phone(Required)Address(Required)Full name(Required)Relationship(Required)Company(Required)Phone(Required)Address(Required) PREVIOUS EMPLOYMENTPlease list three professional references:Company(Required)Phone(Required)Address(Required)Supervisor(Required)Job Title(Required)Starting Salary $(Required)Ending Salary $(Required)ResponsibilitiesFromToReason for leavingMay we contact your previous supervisor for a reference?(Required) Yes No Company(Required)PhoneAddress(Required)Job Title(Required)Starting Salary $(Required)Ending Salary $(Required)ResponsibilitiesFromToReason for leavingMay we contact your previous supervisor for a reference?(Required) Yes No Company(Required)Phone(Required)Address(Required)Supervisor(Required)Job Title(Required)Starting Salary $(Required)Ending Salary $(Required)ResponsibilitiesFormToReason for leavingMay we contact your previous supervisor for a reference?(Required) Yes No BACKGROUND INFORMATIONDo you currently use illegal drugs?(Required) Yes No If so, explain.Have you ever been convicted of a criminal offense?(Required) Yes No If so, explain.Have you ever been convicted of, or is there a pending criminal charge against you for, child abuse or neglect?(Required) Yes No If so, explain.Do you have a driver’s license and meet drivers eligibility requirements?(Required) Yes No If so, explain.Are there any facts or circumstances involving you or your background that would call into question your being trusted with the supervision, guidance, and care of our members?(Required) Yes No If so, explain. DISCLAIMER AND SIGNATURE I certify that my answers are true, and complete to the best of my knowledge. I also certify that I have not withheld any pertinent information. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I agree that in course of considering my application, you may inquire to verify information considering my background. I specifically authorize you to investigate all statements in this application. I authorize educational institutions, employers, personal references, and any agency elicited for background search to give you any and all information concerning my education, employment, and fitness to work with children and young people to the Boys and Girls Club of Hocak Nisoc Haci. I release any institutions and references listed above and any law enforcement agency, from all liability and any damage that may result from furnishing this information to you. It is my understanding that any information obtained will be used by the Boys and Girls Club of Hocak Nisoc Haci solely for the purpose of making employment decisions. SignatureDate MM slash DD slash YYYY
