Westside Domestic Violence Shelter
Application for Employment
Equal Opportunity Employer
Name
Date
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Month
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Day
Year
Date
Address
Phone
Format: (000) 000-0000.
Position applying for
Regular full-time work?
YES
NO
Regular part-time work?
YES
NO
Temporary Work?
YES
NO
What days and hours are you available to work?
If applying for temporary work, during what period of time will you be available?
Are you available to work on weekends?
YES
NO
Are you available to work on call?
YES
NO
If hired, what date can you start?
/
Month
/
Day
Year
Date
Salary desired
Have you ever volunteered or applied to Westside Domestic Violence Shelter before? If yes, when and in what capacity?
Do you have any friends or relatives working for Westside Domestic Violence Shelter? If yes, state name(s) and relationships.
Why are you applying for work at Westside Domestic Violence Shelter?
If hired, would you have a reliable means of transportation?
YES
NO
Are you at least 18 years of age? (If under 18, hire is subject to verification that you are minimum legal age).
YES
NO
If hired, can you present evidence of your US citizenship or proof of your legal right to live and work in this country?
YES
NO
Are you able to preform the essential functions of the job for which you are applying, either with or without reasonable accommodation? (Note: we comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests).
YES
NO
If no, please describe the functions that cannot be performed:
Have you ever been convicted of a criminal offense (felony or misdemeanor)? A background check/live scan is required for employment. (Note: no applications will be denied employment solely on the grounds of conviction of a criminal offense. the nature f the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered).
YES
NO
If yes, state the nature of the crime(s), when and where convicted, and disposition of the case:
Do you speak, write, or understand any foreign languages?
YES
NO
If yes, which language(s)?
Do you have the 40-hour DV certification required in the CA Evidence code 1037?
YES
NO
If yes, when did you receive it and where?
If not, are you willing to take the 40 hour certification?
YES
NO
N/A
Education, Training, Employment, and Experience
Please fill out the following tables or provide a resume
Education
Rows
Name and Address
# of years completed
Did you graduate?
Degree or Diploma
High School
Yes
No
College/University
Yes
No
College/University
Yes
No
Vocational/Business
Yes
No
Other
Yes
No
Employment
Please list all present and past employment for the last five years starting with your most recent employer. Account for all periods of unemployment.
Most Current Employer
Rows
Please type response.
Position
Name of Employer
Supervisor's Name/Phone
Address
Employment start date
Employment end date
Rate of Pay
Position duties
Reason for leaving
May we contact as a reference?
Employer Two
Rows
Please type response.
Position
Name of Employer
Supervisor's Name/Phone
Address
Employment start date
Employment end date
Rate of Pay
Position duties
Reason for leaving
May we contact as a reference?
Employer Three
Rows
Please type response.
Position
Name of Employer
Supervisor's Name/Phone
Address
Employment start date
Employment end date
Rate of Pay
Position duties
Reason for leaving
May we contact as a reference?
Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Westside Domestic Violence Shelter?
Have you obtained any special skills or abilities as the result of service in the military?
YES
NO
If yes, please explain:
Do you have any experience working or volunteering in a confidential capacity?
YES
NO
If yes, please explain:
References
Please list three references (at least two must be professional references).
References
Rows
Name
Phone Number
Relationship
Occupation
# of years known
Reference One
Reference Two
Reference Three
Agreements
Please read carefully, initial each paragraph, and sign below:
I hereby certify that all the above information is true and correct to the best of my knowledge, and that I have personally completed this form.
I hereby authorize Westside Domestic Violence Shelter to thoroughly investigate my references, work history, education, and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the organization any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release my former employers and all other persons, corporations, partnerships, and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I agree to provide a live scan/background check and DMV record if needed. I agree to sign and maintain confidentiality if employed. I am entitled to copies of these documents.
Signature
Date
/
Month
/
Day
Year
Date
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