Employment Application

Personal History

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Available*

Phone*

Type of work desired*

If you are under 18, can you provide required proof of your eligibility to work?

Do you possess a valid driver's license?*

What State?

Have you ever been convicted of a crime?

If yes, list nature and date of conviction(s), your age and time of offense, and your rehabilitation since the conviction*

(A conviction record will not necessarily be a bar to your employment)

Have you ever been employed previously by the YWCA?*

If yes, give date

Work Availablity*

Full Time
Part Time
Temporary

Education

High School

Name of Institution	Location	Years Completed	Major/Courses	Did you Graduate/Degree

College

Name of Institution	Location	Years Completed	Major/Courses	Did you Graduate/Degree

Other

Name of Institution	Location	Years Completed	Major/Courses	Did you Graduate/Degree

Describe any additional training, courses, certificates or licenses related to the position for which you applied.

Describe any honors you have received?

List any languages and indicate for each if you speak, read, and/or write.

List any other education, specialized training, apprenticeship, skills or certifications you possess related to this job.

Skills

Summarize work skills, qualifications and special training acquired from employment or other experiences such as volunteer work (please omit any references to groups which indicate race, color, religion, sex, age, marital status, disability, sexual orientation, citizenship status or national origin.)*

If you have computer experience, please list below what type of computers, programs and the type of experience with each (ie. programming, data entry, word processing, etc.)

Personal References

(Not former employers or relatives)

1. Please list the following:*

Name and Occupation	Address	Phone Number

2. Please list the following:*

Name and Occupation	Address	Phone Number

3. Please list the following:*

Name and Occupation	Address	Phone Number

Volunteer Experience

List volunteer positions held during the last three years which are relevant to this position.

1. Please list the following:

Name, Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position Held	Reason for Leaving

2. Please list the following:

Name, Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position Held	Reason for Leaving

Employment History

May we contact your present employer*

Yes
No

1. Please list the following:*

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

2. Please list the following:*

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

3. Please list the following:*

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

4. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

5. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

6. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

7. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

8. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

9. Please list the following:

Name Address, Phone Number of Employer/Name of Supervisor	Dates From/To	Position	Salary/Hourly Rate	Reason for Leaving

If you need additional space for your employment history, please write here.

If applying for a position which driving is required:

Driver's License #	Name of State	Classification

Indicate those convictions related to moving violations within the last three years; and any suspension, revocation, DWI convictions, or any occurrence involving harm to persons or property while driving:

The YWCA of Ulster County does not discriminate in hiring or employment on the basis of race, color, religion, national origin, sex, marital status, age or disability. No question on this application is intended to secure information to be used for discriminatory purposes. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. In processing this employment application, the YWCA of Ulster County reserves the right to contact pervious employers to verify employment history and personal references. I hereby acknowledge that I have read the foregoing disclosure and understand the same. I also affirm that my answers contained herein are tru and correct and that I have not knowingly withheld any facts or circumstances that would, if disclosed, affect my application.

Date