YMCA of Garfield
33 Outwater Lane
Garfield, NJ 07026
(973) 772-7450 Fax (973) 772-2632
Email: Garfieldymca@optonline.com
LAST NAME FIRST NAME MIDDLE INITIAL DATE ***POSITION DESIRED
PRESENT STREET ADDRESS CITY STATE ZIP YEARS MONTHS
HOME PHONE CELL PHONE EMAIL SOCIAL SECURITY #
PREVIOUS STREET ADDRESS CITY STATE ZIP YEARS MONTHS
PREVIOUS STREET ADDRESS CITY STATE ZIP YEARS MONTHS
PREVIOUS STREET ADDRESS CITY STATE ZIP YEARS MONTHS
HOW DID YOU FIND OUT ABOUT THIS POSITION?
____FRIEND ____ WEB ____ CLASSIFIED AD ____YMCA LISTING _____OTHER
ARE YOU OVER THE AGE OF 18? ______YES _____NO
HAVE YOU EVER WORKED FOR ANY YMCA ____YES ____NO
IF YES:
WHEN: LOCATION
WHEN: LOCATION
WHEN: LOCATION
LIST ANY RELATIVES WORKING FOR THE YMCA
RELATIVE NAME: RELATIONSHIP:
RELATIVE NAME: RELATIONSHIP:
RELATIVE NAME: RELATIONSHIP:
HAVE YOU BEEN CONVICTED OF A CRIME?
______YES _____NO
IF YES, STATE CIRCUMSTANCES, PLACE(S), DATE(S). THE EXISTENCE OF A CRIMINAL RECORD
DOES NOT CONSTITUTE AN AUTOMATIC BAR TO EMPLOYMENT:
ARE YOU A REGISTER SEX OFFENDER? _____YES _____NO
PLEASE COMPLETE ALL SECTIONS
SCHOOL NAME & ADDRESS COURSE OF STUDY CHECK LAST YR. DID YOU
OF SCHOOL COMPLETED GRADUATE?
HIGH SCHOOL __1 __2 __3 __4 ____YES ____NO
COLLEGE __1 __2 __3 __4 ____YES ____NO
OTHER
(SPECIFY) __1 __2 __3 __4 ____YES ____NO
OTHER
(SPECIFY) __1 __2 __3 __4 ____YES ____NO
WE ARE AN EQUAL OPPORTUNITY EMPLOYER AND APPLICANTS WILL BE SELECTED FOR
EMPLOYMENT ON THE BASIS OF THEIR QUALIFICATIONS FOR A GIVEN POSITION AND
WITHOUT REGARD TO ANCESTRY, RELIGIOUS CREED, NATIONAL ORIGIN, GENDER, SEXUAL
ORIENTATION, DISABILITY, VETERAN STATUS, AGE (OVER 40). PHYSICAL OR MENTAL
CONDITION (INCLUDING GENETIC AND ANY OTHER CONSIDERATION MADE UNLAWFUL BY
FEDERAL LAWS.
SKILLS, LICENSES AND CERTIFICATES
PLEASE LIST JOB-RELATED SKILLS, LICENSES AND CERTIFICATES THAT YOU HAVE, SUCH
AS DRIVERS LICENSE, CPR, LIFESAVING CERTIFICATE, FIRST AID, CPA, ETC.
EMPLOYMENT HISTORY
LIST BELOW ALL PAST AND PRESENT EMPLOYMENT, BEGINNING WITH MOST RECENT
1.EMPLOYMENT DATES
FROM: TO:
ADDRESS
JOB TITLE HOURLY RATE/SALARY
STARTING FINAL
SUPERVISOR PHONE NO.
2.EMPLOYMENT DATES
FROM: TO:
ADDRESS
JOB TITLE HOURLY RATE/SALARY
STARTING FINAL
SUPERVISOR PHONE NO.
3.EMPLOYMENT DATES
FROM: TO:
ADDRESS
JOB TITLE HOURLY RATE/SALARY
STARTING FINAL
SUPERVISOR PHONE NO.
4.EMPLOYMENT DATES
FROM: TO:
ADDRESS
JOB TITLE HOURLY RATE/SALARY
STARTING FINAL
SUPERVISOR PHONE NO.
IF ABOVE LISTING DOES NOT INCLUDE ALL OF YOUR JOBS OVER THE PAST TEN YEARS,
DESCRIBE ANY ADDITIONAL JOBS. IF YOU HAVE BEEN OUT OF WORK FOR THREE MONTHS
OR AT ANY TIME SINCE GRADUATION (HS OR COLLEGE) PLEASE EXPLAIN:
HAVE YOU BEEN DISCHARGED FROM ANY JOB POSITION? ____YES ____NO
PROFESSION AND VOLUNTEER ACTIVITIES
LIST PROFESSIONAL, TRADE, BUSINESS OR CIVIC ACTIVITIES AND OFFICES AND POSITIONS
HELD.
REFERENCES
PLEASE LIST AT LEAST THREE (3) PROFESSIONAL AND ONE (1) PERSONAL RELATIVE
REFERENCE
NAME RELATIONSHIP ADDRESS PHONE # EMAIL
SUPPLEMENTAL INFORMATION
USE THIS SPACE TO SUPPLEMENT ANY INFORMATION YOU HAVE GIVEN IN RESPONSE TO
ANY QUESTIONS ON THIS FORM AND/OR TO DESCRIBE ANY ADDITIONAL SKILLS, KNOWLEDGE
OR EXPERIENCE CONCERNING YOUR QUALIFICATIONS FOR THE POSITION FOR WHICH YOU
ARE APPLYING.
FOR JOBS REQUIRING DRIVING ONLY
1. DO YOU HAVE A VALID DRIVER LICENSE IN THIS STATE? ____YES ____NO
2. DO YOU HAVE A VALID CLASS II/B LICENSE IN THIS STATE? ____YES ____NO
3. DO YOU POSSES A YOUTH BUS OR SCHOOL BUS DRIVER CERTIFICATE? ____YES ____NO
4. ARE YOU OVER 21? ____YES ____NO
5. ARE YOU CURRENTLY IN A DRUG OR ALCOHOL TESTING PROGRAM? ____YES ____NO
IN COMPLIANCE WITH U.S. DEPARTMENT OF TRANSPORTATION FHWA, THE YMCA WILL
CONDUCT PRE-EMPLOYMENT DRUG TESTING AND RANDOM DRUG AND ALCOHOL TESTING
ON BUS DRIVERS.
AGREEMENT
I HEREBY CERTIFY THAT ALL ANSWERS AND STATEMENTS MADE ON THIS APPLICATION ARE
COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY
MISLEADING MISREPRESENTATION AND/OR OMISSION OF INFORMATION WILL CAUSE THIS
APPLICATION TO BE REJECTED AND WILL CAUSE FOR TERMINATION OF EMPLOYMENT. I
FURTHER UNDERSTAND THAT FINAL EMPLOYMENT IS BASED ON COMPLETION OF ALL
REQUIREMENTS AND PROCEDURES, INCLUDING INTERVIEW(S), REFERENCE CHECKS,
VERIFICATION, PHYSICAL EXAMINATION AND FINGERPRINTING.
I AUTHORIZE ALL ORGANIZATIONS AND PERSONS NAMED ABOVE TO GIVE INFORMATION
ABOUT ME AND I HEREBY RELEASE THEM FROM ALL LIABILITY.
IF EMPLOYED, I AGREE TO OBSERVE ALL RULES, REGULATIONS, POLICIES, AND PROCEDURES
AS THEY RELATE TO THE YMCA OF GARFIELD EMPLOYEES AT ALL TIMES. I FURTHER
UNDERSTAND THAT, ALTHOUGH I MAY BE EMPLOYED FOR A PARTICULAR POSITION AND
SHOULD IT BE NECESSARY TO ACCEPT DIFFERENT ASSIGNMENTS, WORK SCHEDULES OR
WORKING HOURS. EMPLOYMENT IS AT-WILL AND MAY BE TERMINATED AT ANY TIME BY
EITHER PARTY.
_____I AGREE ____ I DISAGREE
SIGNATURE _______________________________________________ DATE___________________