Employment Application

Position Applying For:*
Date Available:*
MM slash DD slash YYYY
Type of Employment*
- Full time
- Part time
- Work study
- Intern/Practicum
Time Available to Report to Work:*
Please list a time for each day or n/a if you are not available.
Monday: Tuesday: Wednesday: Thursday: Friday: Saturday:
Personal Information
Name*
First Last
Other names by which you have been known:
Home Phone*
Cell Phone
Email*
Referral Source
Address*
Street Address City State ZIP Code
Previous Addresses:
Please include length of time at each address.
Are you a US Citizen?*
- Yes
- No
If no, type of visa:
Education Information
High School - Name & Location:*
Graduated?*
- Yes
- No
Years Completed:
College - Name & Location:
Course of Study:
Graduated?
- Yes
- No
Years Completed:
Degree Earned:
Vocational/Technical Training - Name & Location:
Course of Study:
Graduated?
- Yes
- No
Years Completed:
Degree Earned:
Background Information
Have you ever been in the military?*
- Yes
- No
Which branch of the military?
When did you serve?
Please enter the beginning and ending dates of your service.
Discharge Type:
- Voluntary
- Involuntary
If involuntary, please describe the circumstances:
Professional Societies, Associations, Awards, Publications:
Is there anything that would prohibit you from doing the job for which you are applying?*
- Yes
- No
If yes, please explain:
Do you have a valid driver's license?*
- Yes
- No
If yes, from which state?
Have you ever been involuntarily discharged from a previous employer?*
- Yes
- No
If yes, please explain.
Work Experience
Please give an accurate, complete full-time and part-time employment record. Start with present or most recent employer. Do not write "see resume."
1. Company Name*
Employed From:*
MM slash DD slash YYYY
Employed To:*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Job Title:*
Job Duties:*
Salary From:*
Salary To:*
Reason for Leaving:*
Name of Supervisor:*
May we contact?*
- Yes
- No
Supervisor Phone
2. Company Name
Employed From:
MM slash DD slash YYYY
Employed To:
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Job Title:
Job Duties:
Salary From:
Salary To:
Reason for Leaving:
Name of Supervisor:
May we contact?
- Yes
- No
Supervisor Phone
3. Company Name
Employed From:
MM slash DD slash YYYY
Employed To:
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Job Title:
Job Duties:
Salary From:
Salary To:
Reason for Leaving:
Name of Supervisor:
May we contact?
- Yes
- No
Supervisor Phone
Volunteer Experience
Company Name
Volunteered From:
MM slash DD slash YYYY
Volunteered To:
MM slash DD slash YYYY
Address
Street Address City State ZIP Code
Name of Supervisor:
Phone
Volunteer Title:
Volunteer Duties:
Reason for Leaving:
Personal References
List two references. (Exclude previous supervisors and relatives.)
1. Reference Name*
Phone (Home)*
Phone (Cell)
2. Reference Name*
Phone (Home)*
Phone (Cell)
General Information
Have you ever been employed by a Boys & Girls Club?*
- Yes
- No
Date(s):
Position(s):
Location(s):
What are your skills and interests?
Why do you want to work for the Club and what positions would you prefer?*
Please include any other information you think would be helpful to us in considering you for employment, such as activities, accomplishments, other skills, and abilities, etc.
(Please exclude all information indicative of race, color, religion, national origin, sex, physical or mental disability, protected veteran status or sexual orientation.)
The Boys & Girls Clubs of the Northland is a part of a nationwide and local effort to help assure the protection of children from abuse and exploitation. Therefore, to safeguard the well being of the youth served, the Boys & Girls Club will investigate the accuracy of information provided in the application process for all applicants before appointment can be made. This investigation may include, but is not limited to: reference checking with past employers, the military, schools, appropriate volunteer agencies, police departments and other government agencies.

The Boys & Girls Clubs is an equal opportunity employer (EOE). We are dedicated to a policy of nondiscrimination in employment on any basis; including race, color, creed, religion, national origin, sex, age, marital status, disability, protected veteran status, sexual orientation or status as regard to public assistance.

Applications remain on file for 12 months.

Conditions of Employment: All employees of the Boys & Girls Clubs of the Northland are "at will" employees. As such, they are retained at the discretion of the Chief Professional Officer and the Executive Committee of the Board of Directors. The Boys & Girls Club retains sole discretion to make determinations of appropriate action to be taken in response to appropriate, improper or illegal employee conduct. The Chief Professional Officer and the Executive Committee shall retain sole discretion to determine the definition of inappropriate or improper conduct. Additional policies may be added from time to time as necessary, without prior notice, at the discretion of the Chief Professional Officer or the Executive Committee of the Board of Directors.
Applicant's Statement of Agreement
I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge and agree that falsification or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date.

I authorize persons, schools, current and previous employers and organizations named in this application (and accompanying resume, if any) to provide the Boys & Girls Clubs of the Northland with relevant information that may be required to arrive at an employment decision.

By checking the box below and typing your name into the Signature box, you are confirming that the above statements are true.
Agreement:*
- I agree
Today's Date
MM slash DD slash YYYY
Signature*
You agree that by typing your name, you are electronically signing this document.

Employment

Employment Application

Personal Information

Education Information

Background Information

Work Experience

Volunteer Experience

Personal References

General Information

Applicant's Statement of Agreement