Equal Opportunity Employer Application Form - Ymca - Greater Cleveland, Ohio

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Revised 5/2012
YMCA of
Greater Cleveland
EQUAL OPPORTUNITY EMPLOYER
This application will remain active for 30 days.
Check one:
r Employment Application r Volunteer Application*
PERSONAL INFORMATION
Position
DAtE:
of intErEst:
nAmE:
ADDrEss:
CitY:
stAtE:
ZiP:
PhonE: (
)
EmAiL:
have you ever been employed at any branch of the YmCA of Greater Cleveland? r no r Yes - fill in below.
DAtEs:
BrAnCh:
Position(s):
Are you legally eligible for employment in the UsA? r no r Yes - Verificiation will be required upon employment.
If you are under 18 years of age, can you provide required proof of your eligibility to work? r no r Yes
Expected hourly rate or annual salary? (For Employment Only)
r hourly r Annually
$
have you ever been convicted of a misdemeanor involving theft, misrepresentation or moral turpitude (domestic
violence, assault, battery, child abuse, etc.) or of any felony? Conviction of a crime will not be an absolute bar to
employment or volunteering. r no r Yes - Please provide information request below.
DAtE
PLACE of ConViCtion
tYPE of CrimE AnD ConViCtion
AVAILABILITY
on what date will you be available to begin employment or volunteer?
Please indicate below when you are available to work or volunteer.
monDAY r AM r PM
tUEsDAY r AM r PM
WEDnEsDAY r AM r PM
sUnDAY r AM r PM
thUrsDAY r AM r PM
friDAY r AM r PM
sAtUrDAY r AM r PM
Revised 5/2012
YMCA of
Greater Cleveland
EQUAL OPPORTUNITY EMPLOYER
This application will remain active for 30 days.
Check one:
r Employment Application r Volunteer Application*
PERSONAL INFORMATION
Position
DAtE:
of intErEst:
nAmE:
ADDrEss:
CitY:
stAtE:
ZiP:
PhonE: (
)
EmAiL:
have you ever been employed at any branch of the YmCA of Greater Cleveland? r no r Yes - fill in below.
DAtEs:
BrAnCh:
Position(s):
Are you legally eligible for employment in the UsA? r no r Yes - Verificiation will be required upon employment.
If you are under 18 years of age, can you provide required proof of your eligibility to work? r no r Yes
Expected hourly rate or annual salary? (For Employment Only)
r hourly r Annually
$
have you ever been convicted of a misdemeanor involving theft, misrepresentation or moral turpitude (domestic
violence, assault, battery, child abuse, etc.) or of any felony? Conviction of a crime will not be an absolute bar to
employment or volunteering. r no r Yes - Please provide information request below.
DAtE
PLACE of ConViCtion
tYPE of CrimE AnD ConViCtion
AVAILABILITY
on what date will you be available to begin employment or volunteer?
Please indicate below when you are available to work or volunteer.
monDAY r AM r PM
tUEsDAY r AM r PM
WEDnEsDAY r AM r PM
sUnDAY r AM r PM
thUrsDAY r AM r PM
friDAY r AM r PM
sAtUrDAY r AM r PM
EDUCATIONAL BACKGROUND
SCHOOL
SCHOOL NAME
COURSE OF STUDY
YEARS
DID YOU
DIPLOMA/DEGREE
& ADDRESS
COMPLETED
GRADUATE?
HIGH SCHOOL
COLLEGE
OTHER
(SPECIFY)
Personal Registration, Trade License, Certifications or Accreditations:
TYPE
DATES
REGISTRATION NUMBER
STATE
Summarize any additional information necessary to describe your full qualifications:
EMPLOYMENT BACKGROUND
(List positions in chronological order starting with the most current or most recent position)
EMPLOYER NAME:
r
r
MAY WE CONTACT?
NO
YES
ADDRESS:
CITY:
STATE:
ZIP:
NAME & TITLE OF
PHONE: (
)
IMMEDIATE SUPERVISOR:
STARTING PAY:
ENDING PAY:
POSITION(S) HELD:
REASON FOR
DATE HIRED:
DATE SEPARATED:
SEPARATION:
EMPLOYER NAME:
r
r
MAY WE CONTACT?
NO
YES
ADDRESS:
CITY:
STATE:
ZIP:
NAME & TITLE OF
PHONE: (
)
IMMEDIATE SUPERVISOR:
STARTING PAY:
ENDING PAY:
POSITION(S) HELD:
REASON FOR
DATE HIRED:
DATE SEPARATED:
SEPARATION:
EMPLOYER NAME:
r
r
MAY WE CONTACT?
NO
YES
ADDRESS:
CITY:
STATE:
ZIP:
NAME & TITLE OF
PHONE: (
)
IMMEDIATE SUPERVISOR:
STARTING PAY:
ENDING PAY:
POSITION(S) HELD:
REASON FOR
DATE HIRED:
DATE SEPARATED:
SEPARATION:
By typing my first and last name followed by the last
four digits of my Social Securtiy Number, I hereby give
SIGNATURE:
permission to contact the employers listed above.
PERSONAL REFERENCES
(Not former employers or relatives)
NAME & OCCUPATION
ADDRESS
PHONE NUMBER
YEARS KNOWN
IMPORTANT! PLEASE READ BEFORE SIGNING
My signature constitutes my certification that my responses are true and complete and that I have read and understand this
paragraph. Where an item is left blank, it is because there is no information within its scope. My signature further constitutes
my authorization for the YMCA of Greater Cleveland to investigate the facts submitted and for those with relevant information,
including, but without limitation, physicians, hospitals, schools, law enforcement agencies, my prior employers and/or personal
references to provide such information to the YMCA of Greater Cleveland, and I release them from liability for doing so.
A copy of this form shall serve as my authorization to release information and records. I hereby consent to undergo such drug
screenings and post-offer medical examinations as the YMCA of Greater Cleveland may require (which may include obtaining body
tissue or fluid samples and analysis of them). I understand and agree that any falsification or omission either on this form or in
my response to questions asked during the interviewing or examination process or on employment forms I may subsequently
complete, including “I-9” forms, may result in immediate termination of employment, no matter when the falsification or omission
is discovered.
I also understand that, if hired, my employment is to be “at will” and that either I or my employer may terminate my employment at
any time, with our without cause, unless the “at will” arrangement is modified by a written agreement signed by both myself and
the President of the YMCA of Greater Cleveland.
*I also understand that if I volunteer for the YMCA of Greater Cleveland and have unsupervised access to children, I may be
required to provide a set of fingerprints and a criminal records check as required by the State of Ohio., Am.Sub.SB 187.
By typing my first and last name followed by the last four digits of my Social Security Number, I hereby agree with the
above information.
SIGNATURE:
DATE:
DO NOT WRITE BELOW THIS LINE
Interviewed by:
Date:
If applicant was previously employed at the YMCA of Greater Cleveland, are they eligible for rehire? r No r Yes
VERIFIED BY:
DATE:
Revised 5/2012
YMCA of
Greater Cleveland
EQUAL OPPORTUNITY EMPLOYER
This application will remain active for 30 days.
EMPLOYMENT APPLICATION
DISCLOSURE AND AUTHORIZATION TO BACKGROUND INVESTIGATION
PURSUANT TO THE FAIR CREDIT REPORTING ACT
DISCLOSURE
As an applicant for a position with the YMCA of Greater Cleveland, you have been asked to furnish information
for use in reviewing your background and qualifications. As part of its investigation and consideration of your
application, the YMCA of Greater Cleveland may obtain a consumer report from a Consumer Reporting Agency
which may include information about your background, including your past and present work, character, educa-
tion, military records, court records and criminal records. Before the YMCA of Greater Cleveland takes any ad-
verse action based in whole, or in part, on a consumer report from a Consumer Reporting Agency, it will provide you a
copy of that report and will give you a written description of your rights under the Fair Credit Reporting Act.
AUTHORIZATION
I hereby authorize the YMCA of Greater Cleveland, or any of its agents, to conduct an investigation of my back-
ground and qualifications. I authorize the release of any information pertaining to my background and qualifica-
tions, including those categories of information listed above, whether the information is of public record or not.
I hereby authorize and instruct any Consumer Reporting Agency to provide a consumer report to the YMCA of
Greater Cleveland if it should make such a request.
This authorization shall remain effective for any future investigations by the YMCA of Greater Cleveland.
By typing my first and last name followed by the last four digits of my Social Security Number, I hereby authorize this form.
SIGNATURE:
SOCIAL SECURITY NUMBER:
PRINT NAME:
DATE:
PARENT/GUARDIAN SIGNATURE:
DATE OF BIRTH:
**Applicants under the age of eighteen (18) must have signed approval from a parent or guardian.
Return this form completed at the time of interview.
Do not write below this line.
To:
Human Resources Department
From:
BRANCH NAME:
SENDER:

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