Position Applying For:

First and Last Name:

Address:

Phone Number:

Email Address:

Are you 18 years of age or older?

Date of Birth (if under 18):

Employment type you are looking for:

Shift Available:

Hours Available:

Days Available:

How did you learn of this opening?

Name and relationship of any relatives working for the YMCA of Dodge County:

Have you been a paid employee for the YMCA of Dodge County before?

If yes, when were you employed?

Position/Department you worked in?

If hired, date you are available to start?

Are you legally authorized to work in the U.S.?

Upload Resume Here:

Name of High School attended:

Graduated:

Name of College if attended, if so did you graduate and what were your course or major studies?

Name of Post Graduate school if attended, if so did you graduate and what were you course or major studies?

Name of Business or Trade school if attended, if so did you graduate and what were your course or major studies?

Types of certifications you hold? (examples: CPR & First Aid). Proof of certification may be required prior to employment. Please include the date recieved and expiration date of certifications.

Other extracurricular and/or volunteer activities you have been or are currtently engages in relating to the position you are applying for, including dates.

Briefly describe what you feel makes you qualified to be selected to fill the position(s) you are applying for:

Are you currently employed?

If Yes, current work schedule:

#1. Supervisor's Name or Company Name and Address:

Dates From/To:

Positon Held:

Reason for leaving:

#2. Supervisor's Name or Company Name and Address:

Dates From/To:

Position Held:

Reason for leaving:

#3. Supervisor's Name or Company Name and Address:

Dates From/To:

Postition Held:

Reason for leaving:

#4. Supervisor's Name or Company Name and Address:

Dates From/To:

Position Held:

Reason for leaving:

Reference #1

Name:

Address & Phone Number:

Relationship to Applicant:

Business/Organization:

Reference #2

Name:

Address & Phone Number:

Relationship to Applicant:

Business/Organization:

Reference #3

Name:

Address & Phone Number:

Relationship of Applicant: 

Business/Organization

Signed personal statement

I certify that all the information given by me in this employment application is true and correct without consequential omissions of any kind whatsoever. I understand that any misrepresentation or omission of any facts may render this application void, or if employed, may be cause for termination of employment with the YMCA of Dodge County. I further understand and agree that the filling out of this application does not obligate the YMCA of Dodge County to offer me a job, or obligate me to accept a job. If hired, I understand and agree that my employment is at will and can be terminated with or without reason or notice by me or the YMCA of Dodge County. I understand that no YMCA of Dodge County representative has any authority to make any arrangement to the contrary.

I consent to and authorize the YMCA of Dodge County to make inquiry and to perform reference checks concerning my prior employment, education, character, qualifications, experience and background. In addition, the YMCA of Dodge County may obtain a copy of my driving record if my position requires me to operate a vehicle. I understand that this statement will serve as written authorization for the YMCA of Dodge County to make such inquiries. I understand that it is the YMCA of Dodge County’s policy to secure criminal conviction history information and that my continued employment is contingent upon an acceptable criminal history background check. 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 release said companies, schools, or persons from all liability for any damage for providing information as specified herein.

I understand that the YMCA of Dodge County does not condone child abuse in any form and that the YMCA of Dodge County will be seeking information in my background related to child abuse. I understand that any documented allegations of past incidents of child abuse may eliminate me from further consideration for employment with the YMCA of Dodge County. I also understand that in any event of my employment, the YMCA of Dodge County will take any allegations or suspicions of child abuse seriously and will report such allegations to the police and state agencies for investigation.

In the event of my employment by the YMCA of Dodge County, I will comply with all policies set forth here in after in the personnel handbook and with other policies established by the organization.

I hereby acknowledge that I have read and understand the above statement and that I voluntarily sign this application.