TELEPHONE NUMBER: * CELL PHONE NUMBER: * EMAIL * OTHER NAMES USED * ARE YOU AUTHORIZED TO WORK IN THE UNITED STATES? * ARE YOU AT LEAST 18 YEARS OF AGE? * IF NOT, DO YOU HAVE A WORK PERMIT? * HOW WERE YOU REFERRED TO BOYS & GIRLS CLUBS OF AMARILLO (BGCA)? * PREVIOUS EMPLOYMENT WITH BGCA (If any, give dates, position, location) * RELATIVES EMPLOYED BY BGCA (If any. give dates, positions) * HAVE YOU BEEN CONVICTED OF, PLEAD GUILTY TO, AND/OR PLED NO CONTEST TO A CRIME (FELONY OR MISDEMEANOR, INCLUDING BUT NOT LIMITED TO SEXUAL OFFENDER CRIMES, THEFT, BANKING FRAUD, DRUG AND/OR ALCHOHOL-RELATED OFFENSES, ASSAULT, ETC.)? * ARE YOU CURRENTLY AWAITING TRIAL, SENTENCING OR OTHER DISPOSITION OF A CRIMINAL CHARGE? * If the answer to either question is yes, please explain (state, date, court, type of crime, place of occurrence, 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. * HAVE YOU EVER BEEN DISCHARGED OR REQUESTED TO RESIGN FROM A POSITION? * If so, explain: * POSITION APPLYING FOR POSITION APPLIED FOR * SITE COORDINATOR PROGRAM SPECIALIST BUS DRIVER PROGRAM ASSISTANT OTHER SALARY REQUIREMENTS (minimum or range) * WILLINGNESS TO TRAVEL? (Approximate percentage if position indicates) * EDUCATION NAME AND LOCATION OF HIGH SCHOOL ATTENDED: * DATES ATTENDED * NAME AND LOCATION OF COLLEGE OR UNIVERSITY ATTENDED: * DATES ATTENDED * DEGREE RECEIVED * NAME AND LOCATION OF OTHER SCHOOLS ATTENDED: (Graduate, technical, business, military, etc.) * DATES ATTENDED * DEGREE RECEIVED * Professional Licenses: * List computer or technical skills: * PREVIOUS EMPLOYMENT
WORK EXPERIENCE: Please complete all information, beginning with your current or most recent employer. Include periods of unemployment, self-employment and military service
COMPANY NAME: * YOUR TITLE * COMPANY ADDRESS (Street & Number, City, State, ZIP) * STARTING BASE SALARY: * LAST BASE SALARY: * IF YES, AMOUNT: * SUPERVISORS NAME: * SUPERVISORS TITLE: * TELEPHONE NUMBER OF SUPERVISOR: * MAY WE CONTACT SUPERVISOR? * BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES: * REASON FOR LEAVING: * YOUR TITLE: * COMPANY ADDRESS (Street & Number, City, State, ZIP) STARTING BASE SALARY: * LAST BASE SALARY: * IF YES, AMOUNT: * SUPERVISORS NAME: * SUPERVISORS TITLE: * TELEPHONE NUMBER OF SUPERVISOR: * MAY WE CONTACT SUPERVISOR? * BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES: * REASON FOR LEAVING: * YOUR TITLE: * COMPANY ADDRESS (Street & Number, City, State, ZIP) * STARTING BASE SALARY: * LAST BASE SALARY: * IF YES, AMOUNT: * SUPERVISORS NAME: * SUPERVISORS TITLE: * TELEPHONE NUMBER OF SUPERVISOR: * MAY WE CONTACT SUPERVISOR? * BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES: * REASON FOR LEAVING: * Can you perform this job (as detailed verbally or in the job description) with or without reasonable accommodation? * PERSONAL REFERENCES
Please list three personal references.
PERSONAL REFERENCE #1 NAME: * RELATIONSHIP: * Phone * EMAIL ADDRESS: PERSONAL REFERENCE #2 NAME: * RELATIONSHIP: * Phone * EMAIL ADDRESS: PERSONAL REFERENCE #3 NAME: * RELATIONSHIP: * PHONE NUMBER: EMAIL ADDRESS: QUESTIONNAIRE
IN AN EFFORT TO MAINTAIN CONFIDENTIALITY, THIS PORTION OF THE APPLICATION MAY NOT BE DUPLICATED
Do you use illegal drugs? * Have you ever been charged with child neglect or abuse? * Have you ever been convicted of any crimes against children? * Have you ever been convicted of offenses related to obscenity, pornography, or crimes involving minors? * Have you ever been convicted of a criminal offense? * Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children? * Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to, a domestic order of protection? * Other than the previous; is there any fact or circumstances involving you or your background that would call into question you being entrusted with the supervision, guidance, and care of young people? * Explain any ‘YES’ answers in full * BOYS & GIRLS CLUB OF AMARILLO CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK AUTHORIZATION/WAIVER/INDEMNITY
I hereby give my permission in exchange for good and valuable consideration for the Boys & Girls Clubs of Amarillo to obtain
information relating to my criminal history record.
I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this
organization. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be
repeated at any time.
I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree
to indemnify and defend the Boys & Girls Clubs of Amarillo and each of their officers, directors, employees, and agents and hold
them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and
demands whatsoever (including claims for the negligence, gross negligence, and/or strict liability of the Boys & Girls Clubs of
Amarillo), and any and all related attorneys fees, court costs, and other expenses resulting from the investigation of my
background in connection with my application to become a volunteer/staff member.
The following is my true and complete legal name and all information is true and correct to the best of my knowledge:
Maiden Names or Other Names Used * For How Long? * For How Long? * Social Security Number * Drivers License Number * State of Drivers License * DIGITAL SIGNATURE *
I authorize BOYS & GIRLS CLUBS OF AMARILLO (BGCA) to investigate all statements in this application
and to secure any necessary information from all my employers, references and academic institutions. I
hereby release all those employers, my employment history, my academic credentials or qualifications,
and my suitability for employment with BGCA. I understand that any offer of employment is contingent
upon receipt of a satisfactory report concerning my academic credentials and employment references.
I further understand that any false or misleading statements will be sufficient cause for rejection of my
application if BGCA has not employed me or immediate dismissal if BGCA has employed me. I also
authorize BGCA 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 BGCA form any and all liability for its providing this information.
I understand that nothing in this employment application in BGCA’s policy statements or personnel
guidelines, or in my communications with my BGCA official is intended to create an employment contract
between BGCA and me. I also understand that BGCA 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 BGCA 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.