Boys _ Girls Club of Honolulu Administration

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                                        Boys & Girls Club of Hawaii
                                         Employment Application
                                          (Paid & Volunteer Staff)


The Boys & Girls Club of Hawaii has been part of a nationwide and local effort to help assure the protection of
children from abuse and exploitation. Therefore, in order to safeguard the well being of the youth served, the Boys
& Girls Club of Hawaii will investigate the accuracy of data provided in the application process for all applicants
before appointment of staff can be made. This investigation may include, but is not limited to, reference checking
with past employers, the military, schools, and appropriate volunteer agencies. Finger printing may be required if
you are selected for a position. After employment, a physical health exam may be required by a physician. We are
an “Equal Opportunity Employer.



                                                 Personal Data
Print Last Name: ___________________________________ First: _____________________________ M.I. _______

Home Address: ____________________________________ City: ____________________ Zip Code: ____________

Home Phone: ____________________ Work Phone: __________________ Social Security No. _____-____-_______

Position Applying For: __________________________________________ Date Available: _____________________

               Full-time ______                  Part-time ______                  Volunteer ______

What hours and days are you available: _______________________________________________________________

Willing to Travel:       ______ Yes       ______ No          (Approximate Percentage) ______%

How did you hear about this job or volunteer position? ___________________________________________________


Have you ever been terminated involuntarily from a paid or volunteer position or suspended from an educational
institution? ______ Yes         ______ No        If yes, explain circumstances: ______________________________
__________________________________________________________________________________________________

Can you, after employment submit verification of your legal right to work in the U.S.    ______ Yes ______ No
Have you been bonded? ______ Yes         ______ No        If yes, name of employer(s) ____________________


Are you able to perform the essential functions of this job with or without reasonable accommodation?
______ Yes       ______ No       (Specify): _____________________________________________________________
__________________________________________________________________________________________________

Do you have a valid driver’s license and current no-fault insurance? ______ Yes ______ No
If yes, from which state? _____________________________________________________________________________


                                                    Education

Rev: 9/2000                                              1
    School                  Name and Location                  Major          Graduate            Degree
                                                                              Yes  No
High School




College or
University




Other Schools
(Graduate,
Technical,
Business,
Military, etc.




If you did not graduate from any school you attended, state why? ________________________________________

Job-related professional organizations, associations, awards, publications: _________________________________

____________________________________________________________________________________________

Skills and other interests: _______________________________________________________________________


                                              Military Service


Which Branch? _______________________________________________________________________________

Discharge was: ________ Voluntary       _______ Involuntary     Rank at discharge: ___________________

Explain if involuntary discharge: _________________________________________________________________




Rev: 9/2000                                            2
                                       Work Experience ( Past 5 years)
Show present employer first and work back to last employer. Do not detail duties and responsibilities if described in
attached resume. List all employers for this period. Use additional pages if needed.

Company Name: ___________________________________________ Position/Title: _______________________

Address: _______________________________________ City: ______________________ Zip: _______________

Date Started: ________________________ Date Left: ______________________ Salary: ____________________

Supervisor’s Name & Title: ________________________________________________ Phone: _______________

May we contact your employer? _________ Yes        __________ No

Description of duties and responsibilities: ___________________________________________________________
______________________________________________________________________________________________

Reason for leaving: ______________________________________________________________________________


Company Name: ___________________________________________ Position/Title: _______________________

Address: _______________________________________ City: ______________________ Zip: _______________

Date Started: ________________________ Date Left: ______________________ Salary: ____________________

Supervisor’s Name & Title: ________________________________________________ Phone: _______________

May we contact your employer? _________ Yes        __________ No

Description of duties and responsibilities: ___________________________________________________________
______________________________________________________________________________________________

Reason for leaving: ______________________________________________________________________________


Company Name: ___________________________________________ Position/Title: _______________________

Address: _______________________________________ City: ______________________ Zip: _______________

Date Started: ________________________ Date Left: ______________________ Salary: ____________________

Supervisor’s Name & Title: ________________________________________________ Phone: _______________

May we contact your employer? _________ Yes        __________ No

Description of duties and responsibilities: _______________________________________________________________

Reason for leaving: _________________________________________________________________________________




                                           Work Experience (cont.)
Rev: 9/2000                                               3
Company Name: ___________________________________________ Position/Title: _______________________

Address: _______________________________________ City: ______________________ Zip: _______________

Date Started: ________________________ Date Left: ______________________ Salary: ____________________

Supervisor’s Name & Title: ________________________________________________ Phone: _______________

May we contact your employer? _________ Yes   __________ No

Description of duties and responsibilities: _______________________________________________________________
__________________________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________



Company Name: ___________________________________________ Position/Title: __________________________

Address: _______________________________________ City: ______________________ Zip: __________________

Date Started: ________________________ Date Left: ______________________ Salary: ______________________

Supervisor’s Name & Title: ________________________________________________ Phone: __________________

May we contact your employer? _________ Yes   __________ No

Description of duties and responsibilities: _______________________________________________________________

Reason for leaving: _________________________________________________________________________________


Company Name: ___________________________________________ Position/Title: ___________________________

Address: _______________________________________ City: ______________________ Zip: ___________________

Date Started: ________________________ Date Left: ______________________ Salary: _______________________

Supervisor’s Name & Title: ________________________________________________ Phone: ___________________

May we contact your employer? _________ Yes   __________ No

Description of duties and responsibilities: _______________________________________________________________
__________________________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________




                                 Volunteer Experience (Past 5 Years)

Rev: 9/2000                                          4
Name of Agency/Organization: _____________________________________________ Phone: __________________

Company Name: ___________________________________________ Position/Title: __________________________

Address: _______________________________________ City: ______________________ Zip: __________________

Date Started: ________________________ Date Left: ______________________ Salary: ______________________

Supervisor’s Name & Title: ________________________________________________ Phone: __________________

May we contact your employer? _________ Yes    __________ No

Description of duties and responsibilities: _______________________________________________________________
__________________________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________



Name of Agency/Organization: ___________________________________________ Phone: _____________________

Company Name: ___________________________________________ Position/Title: ___________________________

Address: _______________________________________ City: ______________________ Zip: ___________________

Date Started: ________________________ Date Left: ______________________ Salary: _______________________

Supervisor’s Name & Title: ________________________________________________ Phone: ___________________

May we contact your employer? _________ Yes    __________ No

Description of duties and responsibilities: _______________________________________________________________
__________________________________________________________________________________________________

Reason for leaving: _________________________________________________________________________________


                                       Office & Computer Skills

Typing Skill:   _______ Yes    _______ No      Words Per Minute: _____________

Computer Skills:

____IBM/Compatible     ____Mac PC     ____Windows        ____Excel   ____Word        ____Access

____Microsoft Office   ____Database   ____PowerPoint Other: __________________________________




                                            Personal References

Rev: 9/2000                                          5
Name                       Address                  Phone             Nature of relationship    Length of relationship

1. ________________________________________________________________________________________________

2. ________________________________________________________________________________________________

3. ________________________________________________________________________________________________



I certify that all the answers given by me to all of the questions on this application and any attachment are to the
best of my knowledge true and that I have not withheld any pertinent information.

I authorize the Boys & Girls Club of Hawaii to investigate all statements in this application and to secure any
necessary information from all my employers, references and academic institutions. After being hired for a position
with the Boys & Girls Club of Hawaii, I authorize the Boys & Girls Club to conduct criminal-records checks or any
background checks deemed necessary. I hereby release all of those employers, references, academic institutions and
Boys & Girls Club of Hawaii from any and all liability arising from their giving or receiving information about my
employment history, my academic credentials or qualifications and my suitability for employment with the Boys &
Girls Club of Hawaii. I understand that any offer of employment is contingent upon receipt of satisfactory reports
concerning my academic credentials and employment references. After being hired, I understand that I will be
required to provide a current traffic abstract if my duties include driving a vehicle on behalf of the Boys & Girls
Club.

I further understand that any false or misleading statements will be sufficient cause for rejection of my application if
the Boys & Girls Club of Hawaii has not employed me or immediate dismissal if the Boys & Girls Club has employed
me. I also authorize the Boys & Girls Club of Hawaii 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 the Boys & Girls Club of Hawaii from any and all liability for its providing this
information.

I understand that nothing in this employment application, in the Boys & Girls Club of Hawaii’s policy statements or
personnel guidelines, or in my communications with any Boys & Girls Club of Hawaii official is intended to create
an employment contract between the Boys & Girls Club of Hawaii and me. I also understand that the Boys & Girls
Club 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 if an employment relationship is established, I have the right
to terminate my employment at any time for any reason. I also understand that the Boys & Girls Club of Hawaii
retains the right to terminate my employment at any time for any reason.

I hereby acknowledge that I have read and understand the preceding statements.


Signature: _______________________________________________                          Date: ____________________


EQUAL OPPORTUNITY EMPLOYER: Qualified applicants receive consideration for employment without
discrimination because of gender, age, religion, marital status, race, color, creed, national origin, disability,
citizenship, arrest & court record or sexual orientation.




Rev: 9/2000                                                 6

				
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