APPLICATION FOR EMPLOYMENT

Please answer all questions fully and accurately even if a resume or other materials are attached. This
application may be rejected if answers are vague or incomplete.
The Boys & Girls Club of Harlem is an equal opportunity employer, dedicated to a policy of
nondiscrimination in employment on any basis including race, color, national origin, ancestry, religion,
sex, age, marital status, veteran status, sexual orientation, present or past history of mental disorder,
mental retardation, learning disability or physical disability including, but not limited to blindness.
PERSONAL INFORMATION
Name: ____ _________________________ Date of Application: ____________
Address: _________________________________________________
City:__________________________ State:___ _____________ Zip Code:_ ________
E-mail: ________________ Home Telephone: ______________ Work Telephone: _______________
Position for which you are applying: __ _________ Paid or Volunteer (circle one)
If you are seeking paid employment, what is your desired salary or hourly wage? ___________
Availability to start (day & hour): ____________________________________________
If seeking a seasonal or temporary position, what is the end date of your availability: ________________
Do you have a site preference? (clubhouse & reason)__Boys & Girls Club of Harlem Administrative Office
How did you learn of this position? (check all applicable) _________
Ad __ Depart. of Labor __ School __ Agency __ Walk-in __ BGC Website__ Other_________________
Have you applied to this Club before? ____ Yes ____ No If yes, when? _________________________
Do you have a valid driver’s license? ____ Yes ____ No If yes, State/#? __________________________
Do you have access to an automobile? ____ Yes ____ No If yes, days/hours? _____________________

the charge. the charge. please provide date and place of the offense. approximately how many days have you been absent from work or school in the last three years? Please explain? ______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ You must be at least eighteen (18) years of age to apply for paid employment. . Individuals under the age of eighteen interested in volunteering must be members of the Club and have parental consent. circumstances and the disposition: ____ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever had accused or had a substantiated charge of abuse or neglect? ____ Yes ____ No If yes. charged or convicted of a crime? ____ Yes ____ No If yes. circumstances and the disposition: ____ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Are you able to perform all activities and essential functions of the position for which you are applying with or without accommodation? _________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Other than vacation and holiday.2|Page Have you ever been arrested. please provide date and place of the offense.

giving attention not only to the content of your answers but to their organization. punctuation.): ________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ EMPLOYMENT HISTORY List below your last three employers. grammar. education.3|Page QUALIFYING EDUCATION AND TRAINING Name & Location of School Dates Attended Major or Concentration Did You Graduate Degree and/or Certification List below any licenses or certifications that would be relevant to the position you are applying for (ex: CPR. Why are you applying for this position? What relevant employment. volunteer work. sentence structure. and spelling. their families and the community? . This section must be completed regardless of resume. Public Service License. starting with the most recent. clarity. or experiences have you had which you feel qualify you for this position? What do you feel the Boys & Girls Club of Harlem can and should provide to its members. Red Cross. training. etc. Month & Year From: To: Month & Year From: To: Month & Year From: To: Name & Address of Employer Position Salary Reason for Leaving Name & Address of Employer Position Salary Reason for Leaving Name & Address of Employer Position Salary Reason for Leaving WRITING EXERCISE Please respond to the following questions. Med Cert.

4|Page SUPERVISORY REFERENCES FROM EMPLOYMENT Name: _ _________ Title: __ _____________________________ Organization: ____ _____________________________________ Address: _______________________________ Telephone: ______________E-mail: ___ ___________________ _____________________________________________________________________________________ Name: ___ ________________ Title: __ _________ Organization: __ ________________________________________ Address: ________________________________ Telephone: _________E-mail: _ ______________________ _____________________________________________________________________________________ Name: __ _________________________________________ Title: _____________________ _ Organization: ___ ____________________________________________________ Address: ________ _____________________________________________________ Telephone: _____________E-mail: __ ___________________________________ _____________________________________________________________________________________ PERSONAL REFERENCES Name: __ ______________________ Relationship: ____________________ Address: _____________________________________ Telephone: ____________E-mail: _ ________________________ _____________________________________________________________________________________ Name: ___ _________ Relationship: _________________ Address: _____________________________________________________________________________ __________________________________________________________________________ Telephone: ______________E-mail: _ __________ _____________________________________________________________________________________ .

has any authority to enter into any employment contract for a specified period of time or to otherwise enter into any employment contract on behalf of the Club. other than the Executive Director in writing.5|Page I authorize representatives of the Boys & Girls Club of Harlem to obtain pertinent information from my previous employers. I understand and agree that a false statement or omission constitutes sufficient cause for the withdrawal of any employment offer or my dismissal from any employment resulting from the application. and persons with knowledge of my work history and background to provide information to the Club and also release all such persons from liability and waive any and all claims. satisfactory completion of a motor vehicle clearance. manuals. I authorize my previous employers. I agree and understand that my employment and compensation can be terminated with or without cause and with or without notice at any time at either the option of the Club or myself. It is further understood that unilateral statements of policy which appear or may appear from time to time in employee handbooks. or other Club documents are not contracts and shall not be construed to modify in any way the explicit provisions of the above statement. All offers of hire are conditional based on results of criminal background and protective service checks. and if applicable. . It is further understood that no person. demands or causes of action whatsoever. Applicant’s Signature: ________________________________________ Date: ____________________ A criminal background check is conducted on all Club employees. THIS IS AN EMPLOYMENT APPLICATION AND NOT AN EMPLOYMENT CONTRACT. Further. and other persons with knowledge of my work history and background. in connection with the request for a release of such information. references. references. I hereby certify that the answers given by me in this application are correct and without consequential omissions of any kind.

the charge. law enforcement or state motor vehicle department to determine whether or not they have any information on file. convictions and /or motor vehicle violations that may occur henceforth and throughout the duration of my affiliation with the Club. Military or Selective Service #. circumstances and the disposition: _______________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Have you ever had accused or had a substantiated charge of abuse or neglect? ____ Yes ____ No If yes. and I specifically authorize said agencies to release any and all information to the Club.6|Page Criminal Background Check Information Form I understand that employment with the Boys & Girls Club of Harlem is contingent upon completion of a satisfactory criminal background check. I have listed all prior arrests. The following personal information is true and complete. Passport #):__________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Have you ever been arrested. the charge. Sec. convictions and/or motor vehicle violations. please provide date and place of the offense.e. if any. on the reverse side of the form. please provide date and place of the offense. Alien Registration #. circumstances and the disposition: _________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ . I give the Club permission to check with any criminal justice. I understand that it is my responsibility to report any arrests. charged or convicted of a crime? ____ Yes ____ No If yes. Signature: _____________________________________________________ Date:____ _______________ Name: _______ ___________________________________________________ (Last) (First) (Middle) Maiden Name/Alias: ___ ____________________________________________________________________ Street Address: ____ __________________________________________________________ City: __ ________________________________ State: ________________ Zip:__ _________ Please list prior addresses covering the last ten years on the back of this form Date of Birth: ___________________________ Place of Birth: __ ___________________ Soc. #:__________________ Gender: ____Female_____ Race: _ _____________ Height: ___________ Weight: ________ Eye Color: __Brown________ Hair Color: ___Brown____________ Drivers License Number and State Issued: _______________________________________ Vehicle License Plate Number and State Issued: ________________________________________________________ Miscellaneous Personal Information (i.

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