Boys & Girls Club - Employment Application

Employment Application
Equal Opportunity Employer
The Boys & Girls Club of Adams County (“BGCAC”) is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, marital or other protected status.

INSTRUCTIONS: Please answer all questions accurately and completely. Put “N/A” in any space that does not apply to you. Incomplete applications or applications providing additional non-requested information are considered withdrawn and will not be considered.
General
Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Other Names Used
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you authorized to work in the United States?

YesNo
Are you at least 18 years of age?

YesNo
If not, do you have a work permit? (ignore if you answered 'yes' to the previous question)

YesNo
How were you referred to the Boys & Girls Club of Adams County (BGCAC)
Do you have previous employment with BGCAC (if yes, give dates, position, location)
Relatives Employed by BGCAC (if any, give dates and positions)
Have you been convicted of, plead guilty to, and/or pled NOLO CONTENDRE to a crime (felony or misdemeanor, including but not limited to sexual offender crimes, theft, banking fraud, drug and/or alcohol-related offenses, assault, etc.)?

YesNo
If you answered yes to the previous question, please explain. (state, date, court, type of crime, place of occurrence, and disposition):
Note: Conviction of a crime will not necessarily disqualify you for employment. Each conviction will be judged on its own merit with respect to time and job relatedness.

Position Applied For
Title or Category
Salary Requirements
Date Available

Education
High School: (please give the school name and location, your major, whether or not you graduated and the degree you graduated with)
College or University: (please give the school name and location, your major, whether or not you graduated and the degree you graduated with)
Other Schooling: (please give the school name and location, your major, whether or not you graduated and the degree you graduated with) Example: Graduate, Technical, Business, Military, etc.

Work Experience #1

Please fill out to the best of your ability
Company Name
Your Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Starting Salary
Last Salary
Supervisors Name
Supervisors Title
Supervisors Phone
May we contact this previous employer?

YesNo
Brief description of duties and responsibilities:
Reason for leaving:

Work Experience #2

Please fill out to the best of your ability
Company Name
Your Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Starting Salary
Last Salary
Supervisors Name
Supervisors Title
Supervisors Phone
May we contact this previous employer?

YesNo
Brief description of duties and responsibilities:
Reason for leaving:

Work Experience #3

Please fill out to the best of your ability
Company Name
Your Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Starting Salary
Last Salary
Supervisors Name
Supervisors Title
Supervisors Phone
May we contact this previous employer?

YesNo
Brief description of duties and responsibilities:
Reason for leaving:

Application Continuation

Please fill out to the best of your ability
Can you perform this job (as detailed verbally or in the job description) with or without reasonable accommodation?
Authorization to Release Employment Reference Information

I understand that The Boys & Girls Clubs of Adams County (BGCAC) will attempt to verify statements made on my application and made during my employment interview. I hereby give my permission for my former employers to answer any and all questions based upon information available to them in my prior employment records. I understand that it is possible that my prior employment records may not be accurate. Nonetheless, in consideration of BGCAC’s review of this application and my candidacy for employment, I release BGCAC and all former employers from any liability as a result of the furnishing and receiving of this reference information. I understand that my failure to sign this reference release so BGCAC can contact references and make a full background check of my previous work history will be deemed interference with and a withdrawal of my application for employment.
Do you understand and agree to the above statement?

YesNo
Your Signature

Clear
Current Date

MonthDayYear
Date

Job Applicant Agreement
I understand that The Boys & Girls Clubs of Adams County (BGCAC) requires certain information about me to evaluate my qualifications for employment and conduct its business if I become an employee. I understand that false, incomplete, or misleading statements on this application may be considered sufficient cause for rejection of my application and for dismissal, if discovered after I am employed by BGCAC. The use of this application blank does not indicate there are positions open and does not in any way obligate BGCAC.

I also authorize BGCAC to supply information about my employment record, in whole or in part, in confidence to any prospective employer, government agency, or other party having a legal and proper interest, and I hereby release BGCAC from any and all liability for its providing this information. I understand that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of this investigation.

In consideration of my potential employment, I agree to conform to the rules of BGCAC. I understand that I have the right to terminate my employment at any time with or without notice, with or without cause, and that BGCAC has a similar right. I understand my employment by BGCAC does not constitute a guarantee that any position be continued for any length of time or that any job assignment or shift be permanent. I also understand that BGCAC has the right to modify its policies without giving me any notice of the changes. No promises regarding employment have been made to me. I understand that no one other than the Executive Director of BGCAC has authority to make any other agreement.

The Immigration Reform and Control Act of 1986 requires that, after employment, employers verify the legal work authorization and identity of all new employees. An offer of employment will depend upon BGCAC’s ability to verify this necessary information.

Applications will not be considered active after the position is filled. I understand that BGCAC will attempt to verify statements made on my application and made during my employment interview.
Signature

Clear
Current Date

MonthDayYear
Date

Reference Checks
Please provide us with three references that we may contact about you that are not relation.
Reference #1
Reference Name
Reference Phone Number
How do you know this reference?
Reference #2
Reference Name
Reference Phone Number
How do you know this reference?
Reference #3
Reference Name
Reference Phone Number
How do you know this reference?
Should be Empty:

Employment Application

General

Position Applied For

Education

Work Experience #1

Work Experience #2

Work Experience #3

Application Continuation

Job Applicant Agreement

Reference Checks

Reference #1

Reference #2

Reference #3