Employment Application

Today's Date *

Last Name, First Name, M.I. *

Street Address *

City *

State *

Zip *

Home Phone *

Cell #

Your Email Address *

Social Security # *

Drivers License or State ID #

Date of Birth *

Are You 18 or Older? *

Parent or Guardian Name
(if under 18)

Do you have the legal right to remain and work in the United States? *

YesNo (Proof of identity and authorization is required upon employment.)

Position(s) desired:

Are you available to work:

Full Time Part Time Seasonal

If you chose part-time above please list days and times you prefer:

Volunteer Experience

References

Please List 3 personal references below that are not related to you and that you have known for 1 year or more.

Personal Reference #1 - First and Last Name *

Street Address *

City *

State *

Zip *

Phone *

Personal Reference #2 - First and Last Name *

Street Address *

City *

State *

Zip *

Phone *

Personal Reference #3 - First and Last Name *

Street Address *

City *

State *

Zip *

Phone *

Present or Most Recent Employer *

Employer Phone *

Street Address *

City *

State *

Zip *

Position Held:

Please describe the duties you performed for this employer:

Please enter your supervisor's first and last name: *

May we contact this employer? *

yes no

Former Employer *

Employer Phone *

Street Address *

City *

State *

Zip *

Position Held:

Please describe the duties you performed for this employer:

Please enter your supervisor's first and last name: *

May we contact this employer? *

yes no

Former Employer *

Employer Phone *

Street Address *

City *

State *

Zip *

Position Held:

Please describe the duties you performed for this employer:

Please enter your supervisor's first and last name: *

May we contact this employer? *

yes no

If you have any physical limitations, please explain:

(Please list any and all physical restrictions here.)

YMCA Relatives?

Please list the first and last names of any existing YMCA of Barry County employee or volunteer and your relationship to that person.

Convictions

If you have ever been convicted of an offense other than a minor traffic violation, please describe below:

Child Abuse History

If you have ever been involved in a substantiated case of child abuse or neglect of children, please describe below:

Agreement *

Yes, I hereby authorize the YMCA of Barry County to investigate any and all statements contained in this application for employment. In addition, I specifically authorize the listed prior employers, supervisors, and personal references to furnish all pertinent information they may have, regarding my previous performance and personal character to the YMCA of Barry County. I hereby release all parties from any liability for damages that may result from furnishing such information to the YMCA of Barry County.

I understand that the YMCA of Barry County will obtain a background Criminal Record Check. Any employment offer is conditional until such time as the results of my background check are complete and approved by the Executive Director. I hereby give the YMCA of Barry County permission to obtain a background check of my record.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if selected, falsified statements on this application shall be grounds for dismissal.

**WARNING**

After clicking submit, the next screen will say THANK YOU at the top. If you do not see that screen your application has not been submitted properly. This may be due to certain manditory fields left blank. If so, you will see a notice in red under the field in which information is missing. Fill in any missing information and click submit again. Thanks.

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