Employment ApplicationName* Date MM slash DD slash YYYY Please submit a copy of your Social Security card orBirthCertificate andacopy of your Driver’s License along with this application.Personal InformationName* First Last Phone*OTHER NAMES USED Email* PRESENT ADDRESS*PERMANENT ADDRESS, IF DIFFERENTARE YOU AUTHORIZED TO WORK IN THE UNITED STATES? Yes No ARE YOU AT LEAST 18 YEARS OLD? Yes No HOW WERE YOU REFERRED TO BOYS & GIRLS CLUB OF THE CAPITAL CITY?PREVIOUS EMPLOYMENT WITH BOYS & GIRLS CLUB(if any, give dates, position, location)RELATIVES EMPLOYED BY BOYS & GIRLS CLUB OF THE CAPITAL CITY (if any, give dates, position, location)HAVE YOU BEEN CONVICTED OF, PLED GUILTY TO, AND/OR PLED NOLO CONTENDRETO A CRIME (FELONY OR MISDEMEANOR, INCLUDING BUT NOT LIMITED TO SEXUAL OFFENDER CRIMES, THEFT, BANKING FRAUD, DRUG AND/OR ALCOHOL-RELATED OFFENSES, ASSAULT, ETC.)? If yes, please give place of occurrence, state, date, court, type of crime, disposition)HAVE YOU BEEN CONVICTED OF, PLED GUILTY TO, AND/OR PLED NOLO CONTENDRETO A CRIME (FELONY OR MISDEMEANOR, INCLUDING BUT NOT LIMITED TO SEXUAL OFFENDER CRIMES, THEFT, BANKING FRAUD, DRUG AND/OR ALCOHOL-RELATED OFFENSES, ASSAULT, ETC.)?* If yes, please give place of occurrence, state, date, court, type of crime, disposition Yes No Please give place of occurrence, state, date, court, type of crime, dispositionNote: 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 relevance to the jobpositionEMPLOYMENT DESIREDTITLE OR CATEGORY SALARY REQUIREMENTS DATE AVAILABLE DO YOU HAVE TRANSPORTATION OR WILL YOU WALK? Are you seekingemployment Full-Time Part-Time Temporary Summer EDUCATIONHIGH SCHOOL NAME & LOCATIONMAJOR GRADUATE? YES NO DEGREE COLLEGE OR UNIVERSITY NAME & LOCATIONMAJOR GRADUATE? YES NO DEGREE OTHER SCHOOLS(e.g. Graduate, technical, military) NAME & LOCATIONMAJOR GRADUATE? YES NO DEGREE WORK HISTORYStart with current or last employer first. Do not detail duties and responsibilities ifdescribed in attached résuméCOMPANY NAME YOUR TITLE COMPANY ADDRESSSTART DATE END DATE STARTING SALARY ENDING SALARY SUPERVISOR’S NAME SUPERVISOR’S TITLE TELEPHONE NUMBER MAY WE CONTACT EMPLOYER? BRIEFLY DESCRIBE YOUR DUTIES & RESPONSIBILITIESREASON FOR LEAVINGCOMPANY NAME YOUR TITLE COMPANY ADDRESSSTART DATE END DATE STARTING SALARY ENDING SALARY SUPERVISOR’S NAME SUPERVISOR’S TITLE TELEPHONE NUMBER MAY WE CONTACT EMPLOYER? BRIEFLY DESCRIBE YOUR DUTIES & RESPONSIBILITIESREASON FOR LEAVINGPLEASE PROVIDE ANY RELEVANT WORK OR VOLUNTEER EXPERIENCE DEALING WITH CHILDREN.Company Name: Your Title: Start Date/End Date: Supervisor Name/Title/Telephone Number: Reason for leaving:PLEASE PROVIDE ANY RELEVANT WORK OR VOLUNTEER EXPERIENCE DEALING WITH CHILDRENCompany Name: Your Title: Start Date/End Date: Supervisor Name/Title: Supervisor Name/Title: Reason for leaving:REFERENCESName ContactRelationship Name ContactRelationship Name ContactRelationship AUTHORIZATION TO RELEASE EMPLOYMENT REFERENCE INFORMATIONI understand that Boys & Girls Club of the Capital City (BGCC) will attempt to verify statements made on my application and made during my employment interview. I understand that the Boys & Girls Club of the Capital City must perform a criminal background check on me because I will be working with and around children. I hereby give my permission for my former employers to answer any and all questions based upon information available to them in my prior employment records. I understand that it is possible that my prior employment records may not be accurate. Nonetheless, in consideration of BGCC’s review of this application and my candidacy for employment, I release BGCC and all former employers from any liability as a result of the furnishing and receiving of this reference information. I understand that my failure to sign this reference release so BGCC can contact references and make a full background check of my previous work history will be deemed interference with and a withdrawal of my application for employment.(*Place your INITIALS in the appropriate space to indicate and document your consent to this authorization.)Name Date MM slash DD slash YYYY JOB APPLICANT AGREEMENTI understand that BGCC requires certain information about me to evaluate my qualifications for employment and conduct its business if I become an employee. I understand that false, incomplete, or misleading statements on this application or my résumé may be considered sufficient cause for rejection of my application and for dismissal, if discovered after I am employed by BGCC. The use of this application blank does not indicate there are positions open and does not in any way obligate BGCC. I also authorize BGCC 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 BGCC from any and all liability forits providing this information. I understand that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of this investigation.In consideration of my potential employment, I agree to conform to the rules of Boys & Girls Clubs of America (BGCA). I understand that I have the right to terminate my employment at any time with or without notice, with or without cause, and that BGCC has a similar right. I understand my employment by BGCC does not constitute a guarantee that any position be continued for any length of time or that any job assignment or shift be permanent. I understand that I may be required to work scheduled and unscheduled overtime and scheduled weekend and holiday work when required by BGCC. I also understand that BGCC 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 no one other than the Board of Directors of the BGCC has authority to make any other agreement. The Immigration Reform and Control Act of 1986 require that, after employment, employers verify the legal work authorization and identity of all new employees. An offer of employment will depend upon BGCC’s ability to verify this necessary information. Applications will not be considered active after the position is filled. I understand that BGCC will attempt to verify statements made on my application and made during my employment interview. I hereby acknowledge that I have read and understand the preceding statementsName Date MM slash DD slash YYYY EQUAL OPPORTUNITY EMPLOYER. Qualified applicants receive consideration for employment without discrimination because of age, sex, religion, marital status, race, color, creed, national origin or disability. (Revised 2/14/08 WHP)SAMPLE COMBINED DISCLOSURE AND AUTHORIZATION: As the employer or end-user of consumer reports, it is your responsibility to ensure compliance with all of the relevant federal, state and local laws governing this area. [If you are located in California or obtain consumer reports on California residents, please refer to www.fadv.com/legal/ca also you may request a copy of our Sample CA Disclosure and Authorization Form. We strongly recommend that prior to use, you consult with an attorney. COMBINED DISCLOSURE NOTICE AND AUTHORIZATION REGARDING BACKGROUND CONSUMER REPORTS Important: Please read carefully before signing. DISCLOSURE A consumer report and/or investigative consumer report including information concerning your character, employment history, general reputation, personal characteristics, police record, criminal records, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness may be obtained in connection with your application for and/or continued employment with the employer. A consumer report and/or an investigative consumer report may be obtained at any time during the application process or during your employment with the company. These reports may include experience information along with reasons for termination of past employment. Further, understand that information from various Federal, State, local and other agencies which contain your past activities may be requested. A consumer report containing injury and illness records and medical information may be obtained after a tentative offer of employment has been made. The name, address and telephone number of the Company preparing the report is: First Advantage P.O. Box 3367 Seminole, FL 33775-3367; Toll free number: 1-800-321-4473 ext. 8. Their privacy Policy can be reviewed at http://www.fadv.com/privacy-policy. Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, and a summary of your rights under the Fair Credit Reporting Act. For California applicants only, if public record information about your character, general reputation, personal characteristics, and mode of living is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information within seven (7) days of the employer’s receipt unless you check this box where you hereby wave your right to obtain a copy of the investigative consumer report .Please be advised that you have a right to inspect the files that the Consumer Reporting Agency may have on you during normal business hours and upon you furnishing proper identification. For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box.For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box. If checked and you are a California applicant, a copy of the consumer report will be sent within three (3) days of the employer receiving a copy of the consumer report. For California applicants only, if public record information about your character, general reputation, personal characteristics, and mode of living is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information within seven (7) days of the employer’s receipt unless you check this box where you hereby wave your right to obtain a copy of the investigative consumer reportFor California applicants only, if public record information about your character, general reputation, personal characteristics, and mode of living is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information within seven (7) days of the employer’s receipt unless you check this box where you hereby wave your right to obtain a copy of the investigative consumer report Please check AUTHORIZATIONBy signing below, you hereby authorize withoutreservation, any party or agency contacted by this employer to furnish the above mentioned information. You further authorize ongoing procurement of the above mentioned reports at any time during your employment (or contract). You also agree that a fax orphotocopy of this authorization with your signature be accepted with the same authority as the original.You hereby authorize and request, without any reservation, any present or former employer, school, police department, financial institution, divisionof motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish First Advantage with any and all background information in their possession regarding you, in order that your employment qualifications may be evaluated.Name: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Security Number:Driver’s License State License NumberThe following is for identification purposes only to perform the background check:Date of Birth (MM/DD/YYYY) Race Gender Male Female Other or Former Names Professional License State Type Number Signature Date MM slash DD slash YYYY Please accomplish the Work Registration Form to complete your job application. 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