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1 Y of WEST SAN GABRIEL VALLEY APPLICATION for EMPLOYMENT (AN EQUAL OPPORTUNITY EMPLOYER) PLEASE READ BEFORE COMPLETING THIS APPLICATION This association does not discriminate in the recruitment, hiring, and conditions of employment on the basis of race, color, religion, national origin, sex, marital status, disability, age or veteran status. No question on this application is intended to secure information to be used in a discriminatory manner. Your completed application will be reviewed carefully; but, its receipt does not imply that you will be employed. Employment consideration necessitates that you meet all minimum qualifications required for the position for which you are applying. PERSONAL DATA (ANSWER ALL QUESTIONS COMPLETELY) Name: Date: / / Last First Middle Address: Street City Zip Telephone: Home: ( ) Business: ( ) Cellular: ( ) Are you 18 years of age or over? Yes No Are you a veteran? Yes No Dates of military service: Are you authorized to work in the United States? Yes No (If you are hired you will be required to furnish proof of your employment eligibility). Other names used during prior employment: Maiden Name; Other Surnames FURNISH THIS INFORMATION ONLY IF REQUESTED Social Security Number: - - Driver s License Number: State: Class: How many moving violations during the last 12 months: Do you currently have liability insurance? GENERAL Applying for position as: Acceptable Salary Range: Full-Time Part-time Date available: If applying for seasonal work, are you available to work during the school term (as applicable)? Yes No Have you previously applied for employment from any YMCA? Yes No Worked for any YMCA? Yes No If so, when? Location: How did you learn about the YMCA? Employee School Drop-in Agency Advertisement Other Name of referral source indicated above: Have you ever pleaded guilty to or have been convicted of a criminal offense? Yes No If yes, give dates and circumstance(s): Have you failed to be re-employed or ever been involuntary discharged, fired or asked to resign a position? Yes No If yes give dates and circumstance(s):

2 EDUCATION PRINT NAME, CITY & STATE DATES TYPE OF COURSE GRADUATED? DEGREE FOR EACH SCHOOL LISTED OR MAJOR High School College College Post-Graduate Trade, Business School Other Are you presently in school? Yes No If yes, give expected completion date: List courses you are taking: If not a high school graduate, indicate highest grade completed: If not a high school graduate, have you earned a General Educational Development (GED) or high school equivalency? Yes No SPECIAL SKILLS Describe any volunteer work, other experience, interest, training, or honors received in connection with your service to any Organizations which you consider relevant to your ability to perform the job sought: _ List all current special license(s), permit(s), certification(s) and level or credited hours. (e.g. CPR.; lifeguard; first aid) Type Level Expiration Date List Proficiency in equipment or machinery or special skills that your posses that will strengthen your ability to perform the functions of the position you seek: List languages you speak: -2-

3 EMPLOYMENT LIST ALL POSITIONS YOU HAVE HELD, BEGINNING WITH YOUR MOST RECENT. INCLUDE SELF- EMPLOYMENT AND VOLUNTEER WORK. ATTACH AN ADDITIONAL SHEET IF NECESSARY. Current or last employer: Employed from: to _ Employer at job before current/last one: Employed from: to _ Employer at two jobs before current/last one: Employed from: to _ -3-

4 PERSONAL REFERENCES* * Not relatives or employers NAME ADDRESS AND PHONE NUMBER FIRM NAME, ADDRESS, AND PHONE NUMBER POSITION OR OCCUPATION HOW LONG KNOWN LIST BELOW THE NAMES OF RELATIVES, FRIENDS, OR ACQUAINTANCES EMPLOYED BY THIS ASSOCIATION AND THEIR RELATIONSHIP TO YOU: PLEASE READ CAREFULLY BEFORE SIGNING I hereby certify that the information provided on this application is accurate to the best of my knowledge and subject to verification by the Y of West San Gabriel Valley. I authorize the schools, persons, previous employers, agencies and other organizations named in this application to provide the Y of West San Gabriel Valley (its authorized employees, agents or representatives) with my relevant information that may be required to arrive at an employment decision and hereby release any such schools, persons, employers, agencies and organizations from any and all liability which they might otherwise incur as a result. I understand that any misrepresentation or omission of a material fact on my application may be justification for refusal of employment. In the event that I am employed, I understand that all employees are subject to termination at the discretion of the Y of West San Gabriel Valley. If, in the event that I choose to voluntarily terminate my employment, I am free to do so at any time; and, if I choose to give proper notice of termination, the association may either permit me to continue my employment during the notice period or may accept my resignation immediately. I understand that, if employed, any misrepresentation made by me completing this application shall be considered as sufficient cause for my dismissal without advance notice. I authorize the Y of West San Gabriel Valley to supply my employment record, in whole or in part, and in confidence, to any prospective employer, government agency, or other party, with a legal and proper interest. In the event of my employment I will comply with all rules and regulations as set forth by the Y of West San Gabriel Valley or other communications distributed to employees, and understand a condition of my continued employment will be my compliance with the Y s controlled substance abuse and testing policy. I have read, understand, and support the Y of West San Gabriel Valley s position on the problem of child abuse. I also understand that my employment is conditional upon my satisfactorily passing a physical examination and/or drug screening, if one is requested, to be given by a physician or registered nurse selected by the Y of West San Gabriel Valley, and until results of my driving record, my criminal history record, reference checks, and other documents required by law are completed, and until information given by me has been verified. I understand that completion of this form does not guarantee me status as an applicant or any consideration for employment unless I meet all stated minimum qualifications required of the position for which I am asking to be considered. CONVICTIONS: A conviction does not automatically mean you will not be offered a job. What you were convicted of, the circumstances surrounding the conviction and how long ago the conviction occurred are important considerations in determining you eligibility. Give all the facts, so that a fair decision can be made. I have read the above statement and accept the same as a condition of my employment with the Y of West San Gabriel Valley. Signature of Applicant Date -4-

5 STATEMENT OF JOB APPLICANT The Y of West San Gabriel Valley strives to attract the highest quality staff. I have been advised that as part of the application process for employment, an extensive inquiry will be made concerning my prior employment, activities, and character. This inquiry will include convictions, criminal history information and information in my background related to child abuse. I fully consent to and authorize all such inquiries. I will provide the requested information for the sole purpose on obtaining a conviction-only criminal history file search. I understand that my continued employment is contingent upon a clean criminal history background check and a physician s statement showing me to be in good health. I authorize the Y of West San Gabriel Valley to request my employment records from any former employer(s). I further understand that inquiries may be made concerning my background experience and prior employment. I waive any right to claim that any request or investigation is an invasion of my privacy, since it is made with my consent; and, it is in my interest that I am considered for employment. I also release the Y of West San Gabriel Valley from any liability, regarding sharing with third parties any child abuse information gathered in this background check or observed during my employment with the Y of West San Gabriel Valley. In the event of my employment by the Y of West San Gabriel valley, I will comply with all policies set forth in the personnel manual and with other policies established from time to time by the Y of West San Gabriel Valley. I also understand that if hired as a Y employee or volunteer, I am not allowed to fraternize with Y of West San Gabriel Valley youth members or participants outside of Y programs, including, but not limited to, babysitting or inviting children to my place of residence. I understand that the Y of West San Gabriel Valley will take any allegations or suspicions of child abuse seriously and will report such allegations to the police and state agencies for investigation. I understand and agree that if I am employed, there is no contract period for employment; and, my employment would be solely employment at will, giving either me or the Y of West San Gabriel Valley the right to terminate my employment at any time without liability or obligation except for my regular pay through the date of termination. I certify that all statements made by me on this application are true to the best of my knowledge; and, that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand and agree that any representation or omission of facts would exclude my being considered from employment. Any misrepresentation of facts discovered after employment may be cause for termination of employment with the Y of West San Gabriel Valley. I hereby acknowledge that I have read and understood the above; and, that I voluntarily sign this application. Signature of Applicant Date -5-