Boys & Girls Clubs of Barron County Employment Application Form
Please complete the application and submit for consideration.  Thank you!
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General Information
Name *
Other Names Used (if applicable) *
Home Phone Number *
Cell Phone Number  *
Address *
Emergency Contact & relationship  *
Are you authorized to work in the United States? *
Are you at least 18 years of age?  *
How did you hear about the Boys and Girls Club? *
Have you been convicted of, plead guilty to, and/or pled nolo contendre to 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 explain (state, date, court, type of crime, place of occurrence, disposition): *
Position Applying For
Please indicate which position(s) you are applying for:
Salary Requirements *
Date Available *
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Willingness to travel?  (Approximate percentage if position indicates) *
Education
High School (Name and Location) *
Did you graduate? *
College or University (please include your major or degree obtained) *
Did you graduate? *
Other Schools (Graduate, technical, business, military, etc) *
Did you graduate? *
If yes, please include your major or degree obtained *
Work Experience
Start with current or last employer first.  Do not detail duties and responsibilities if described in attached resume.
Company Name *
Your Title *
Company Address (street and number) *
City, State and Zip Code *
Start Date  *
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End Date *
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Starting Salary  *
Last Salary *
Supervisor's Name *
Supervisor's Title *
Telephone Number *
May we contact employer? *
Brief description of duties and responsibilities *
Reason for leaving *
Company Name *
Your Title *
Company Address (street and number) *
City, State and Zip Code *
Start Date *
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End Date *
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Starting Salary *
Last Salary *
Supervisor's Name *
Supervisor's Title *
Telephone Number *
May we contact employer? *
Brief description of duties and responsibilities *
Reason for leaving *
Company Name *
Your Title *
Company Address (street and number) *
City, State and Zip Code *
Start Date *
MM
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YYYY
End Date *
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Starting Salary *
Last Salary *
Supervisor's Name *
Supervisor's Title *
Telephone Number *
May we contact employer? *
Brief description of duties and responsibilities *
Reason for leaving *
Can you perform this job (as detailed verbally or in the job description) with or without reasonable accommodation?
 *
Please provide at least 2 personal references and at least 1 professional reference along with phone and email address. *
Do you have any affiliation with any youth serving organizations?
 *
Do you have previous employment or volunteer experience with the Boys and Girls Clubs?
 *
If yes, please list the names of the Boys & Girls Clubs and the names of your supervisor: *
Authorization to Release Employment Reference Information

I understand that Boys & Girls Clubs of Barron County will attempt to verify statements made on my application and made during my employment interview.  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 BGC-BC review of this application and my candidacy for employment, I release BGC-BC 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 BGC-BC 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.

 *
Signature (type in name) *
Date *
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Authorization and Understanding

I certify that all information submitted in this employment application form, interview, or other information is true and complete, and that I have not knowingly withheld, nor will I withhold, any information that would affect my application or employment. I understand the employer is under no obligation to consider or reconsider my application at any time and that acceptance of this application does not constitute an offer of employment. I also understand that:

Inquiry may be made with my previous employers or others (including private or government agencies) who may have knowledge of me. I authorize any such person or agency to give you all information concerning my previous employment, including but not limited to, an assessment of my job performance, ability and fitness, and/or damages that may directly or indirectly result from furnishing.

Prior to beginning work or during my volunteer employment, the employer reserves the right to require any lawful form of medical, drug, alcohol, psychological character, honesty, integrity, aptitude, skill or other test examination.

To the best of my knowledge, the information herein is true and complete. I understand that falsification of this application will be grounds for elimination from further consideration, or if employed, for dismissal at any time.

Signature (type in name) *
Date *
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Criminal Background Check
Name (first, middle and last name) *
Social Security Number *
Date of Birth *
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Email Address *
Signature (type in name) *
Date *
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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.


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