I Personal

Name	Last	First	Middle	Position Applied For
Present Address	Street		City	State	Zip Code
Home Phone		Other Message Phone	Email	Social Security No.
How did you find out about this position? Friend  Web  Classified Ad  YMCA Listing  Other
Are you over the age of 18? Yes  No    If not, please attach work permit.
If hired, will you be able to provide proof of eligibility to work in the United States? Yes  No
Have you ever worked for the YMCA? Yes  No If yes:   When Location   When Location   When Location
List any relatives working for the YMCA Relative Name Relationship
Have you been convicted of a crime? (Exclude any Marijuana offenses that are over two years old and minor traffic violations for which the fine was $50.00 or less before April 4, 1994 or $100.00 or less after April 5, 1994.) Yes  No If yes, state circumstances, place(s), date(s). The existence of a criminal record will not constitute an automatic bar to employment: Are you a registered sex offender? Yes  No

PLEASE COMPLETE ALL SECTIONS - EVEN IF YOU ARE FURNISHING A RESUME

II Record of Education

School	Name and Address of School	Course of Study	Check Last Year Completed	Did you Graduate?	List Diploma or Degree
High School			1 2 3 4	Yes No
College			1 2 3 4	Yes No
Other (Specify)			1 2 3 4	Yes No
Other (Specify)			1 2 3 4	Yes No
We are an equal opportunity employer and applicants will be selected for employment solely on the basis of their qualifications for a given position and without regard to race, color, ancestry, religious creed, national origin, gender, sexual orientation, disability, marital or veteran status, age (over 40). Physical or mental condition (including genetic characteristics) or any other consideration made unlawful by federal laws.

III Skills, Licenses and Certificates

Please list job-related skills, licenses and certificates that you have, such as drivers license, CPR, Lifesaving Certificate, First Aid, CPA, etc.

IV Employment History
List below all past and present employment, beginning with most recent.

1. Employer		Dates		Work Performed
		From	To
Address
Job Title		Hourly Rate/Salary
		Starting	Final
Supervisor	Phone No.

2. Employer		Dates		Work Performed
		From	To
Address
Job Title		Hourly Rate/Salary
		Starting	Final
Supervisor	Phone No.

3. Employer		Dates		Work Performed
		From	To
Address
Job Title		Hourly Rate/Salary
		Starting	Final
Supervisor	Phone No.

4. Employer		Dates		Work Performed
		From	To
Address
Job Title		Hourly Rate/Salary
		Starting	Final
Supervisor	Phone No.

If above listing does not include all of your jobs over the past ten years, describe additional jobs on page 3. If you have been out of work for three months or more at any time since graduation (HS or College) Please explain:  Have your been discharged from any job position? Yes   No

V Professional and Volunteer Activities

List Professional, trade, business or civic activities and offices and positions held.

VI References
Please list at least three (3) professional and one (1) personal or relative reference.

Name	Relationship	Address	E-mail	Phone Number

VII Supplemental Information

Use this space to supplement any information you have given in response to other questions on this form and/or to describe any additional skills, knowledge or experience concerning your qualifications for the position for which you are applying.

VIII For Jobs Requiring Driving Only

1. Do you have a valid driver license in this state?	Yes	No
License No.   Exp. Date:
2. Do you have a valid Class II/B license in this state?	Yes	No
3. Do you posses a youth bus or school bus driver certificate?	Yes	No
4. Are you over 21?	Yes	No
5. Are you currently in a drug or alcohol testing program?	Yes	No
In compliance with U.S. Department of Transportation FHWA, the YMCA will conduct pre-employment drug testing and random drug and alcohol testing of Bus Drivers.

Agreement

I hereby certify that all answers and statements made on this application are complete and true to the best of my knowledge. I am not a pedophile or child molester and have never been convicted of either. I understand that any misleading misrepresentation and/or omission of information will cause this application to be rejected and will cause for termination of employment. I further understand that final employment is based on completion of all employment requirements and procedures, including interview(s), reference checks, verification, Physical examination and fingerprinting. I authorize all organizations and persons named above to give information about me and I hereby release them from all liability. If employed, I agree to observe all rules, regulations, policies, and a procedure as they relate to the YMCA of San Francisco employees at all times. I further understand that, although I may be employed for a particular position and shift, it may be necessary to accept different assignments, work schedules or working hours. Employment is at-will and may be terminated at anytime by either party.

I Agree    I Disagree