This association does not discriminate in hiring or employment on the basis of race, color,
religion, sex, national origin, age, non-job related medical condition or handicap, veteran or
marital status. No question on this form is intended to secure information to be used for such
discrimination. Please contact the Human Resources Department if you require accommodation
to complete the application or interview process.

1. Personal Information

Position Desired

Application Date:

13-May-2008

Available for

Full-time

Part-time

Temporary

Date Available:

Name (in full)

Last

First

Middle

Address

Street

City

State

Zip

Phone

Social Security Number:

Email:

Are you at least 21?

Yes

Date of birth, if under 21:

State briefly your qualifications and reasons for wanting employment with us.

Employee Referral?

Yes

Employee's Name

Are you a former YMCA Employee?

Yes

Where:

When:

Are you a former YMCA Volunteer?

Yes

Where:

When:

Do you have relatives employed by this YMCA?

Yes

Where:

When:

Have you been convicted of a crime or released from prison in the past 7 years?	Yes	No
If yes, explain:

A conviction record will not necessarily be a bar to employment. Factors such as age at the time of the offense, seriousness and nature of the violation, relevance of the offense to the position applied for and rehabilitation, will be taken into account.

2. EMPLOYMENT / VOLUNTEER HISTORY

Please include month and year of dates employed

Present or Last Employer

Company Name

Supervisor's Name

Phone

Address

Reason for Leaving

May we Contact? Yes No

Position

Full-time

Part-time

Hrs/wk.

Dates Employed

From:

To:

Salary

Begin:

End:

Duties

Next Previous Employer

Company Name

Supervisor's Name

Phone

Address

Reason for Leaving

May we Contact? Yes No

Position

Full-time

Part-time

Hrs/wk.

Dates Employed

From:

To:

Salary

Begin:

End:

Duties

Next Previous Employer

Company Name

Supervisor's Name

Phone

Address

Reason for Leaving

May we Contact? Yes No

Position

Full-time

Part-time

Hrs/wk.

Dates Employed

From:

To:

Salary

Begin:

End:

Duties

Next Previous Employer

Company Name

Supervisor's Name

Phone

Address

Reason for Leaving

May we Contact? Yes No

Position

Full-time

Part-time

Hrs/wk.

Dates Employed

From:

To:

Salary

Begin:

End:

Duties

3. EDUCATION AND TRAINING

Highest year of education completed:

School Name

City

State

Dates Attended

Degree Obtained

Major/Minor

High School

From:

To:

College or University

From:

To:

Other College or University

From:

To:

4. REFERENCES

(Exclude relatives & former employers)

Name

City

State

Day Phone

Evening Phone

Occupation

Name

City

State

Day Phone

Evening Phone

Occupation

Name

City

State

Day Phone

Evening Phone

Occupation

Please read before submitting
The YMCA of Tacoma-Pierce County is committed to providing a safe environment for our
members, participants and employees. We are aware that there are people who seek employment
working near children for the wrong reasons. Therefore, through the initial screening process and
on-going supervision, we do everything in our power to monitor the safety and well-being of our
members and staff. In order for the YMCA of Tacoma-Pierce County to attract the highest quality
staff, extensive inquiries may be made concerning your prior employment and background.

I have read the previous statement and I authorize the YMCA of Tacoma-Pierce County to request my employment record from any former employers. I further understand that inquiries may be made to any governmental agency, including law enforcement agencies or departments. I hereby waive any right to claim that any request or investigation is an invasion of my privacy, since they are made with my consent. I hereby affirm that my answers to the foregoing questions are true and correct, and that I have not knowingly withheld any fact or circumstances that would, if disclosed, affect my application unfavorably. I understand that any falsification or omission on this application may result in my discharge; and that my employment may be subject to fingerprinting, proof of age, and proof of U.S. citizenship or legal right to work in this country. The U.S. Department of Justice Immigration and Naturalization Service has issued a very clear employment verification process. I understand and agree that if I am hired, I will provide necessary and acceptable documents verifying employment eligibility, or receipts of applications for such documents. I understand and agree that if employed, my employment is for no definite period and may be terminated at any time without previous notice. I further understand that no promises or representations contrary to this application or the written policies of the association are binding unless made in writing and signed by the President/CEO of the YMCA of Tacoma-Pierce County.