231 Front Street, Lahaina, HI 96761 info@mynonprofit.com 808.123.4567

Job Application

1Personal

2BACKGROUND INFORMATION

3EMPLOYMENT HISTORY

4EMPLOYMENT REFERENCES

5Please read carefully prior to signing

EMPLOYMENT HISTORY
(Complete Regardless of Attachments – DO NOT USE “See Resume” Begin with most recent position)

List ALL previous employment, starting with your most recent/last position, including military experience & work background. Make sure you include volunteer work or other job related training which provides information on skills/abilities you have developed. Account for any time during this period that you were unemployed by stating the nature of your activities. Please indicate if you were employed under a different name. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.
Employer (Complete Name)
Address
Street Address Address Line 2 City State ZIP Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Job Title
Immediate Supervisor
May we contact your employer?
- Yes
- No
Phone Number
Description of Duties
Have you received any disciplinary actions or were you terminated? If yes, please explain:
Employer (Complete Name)
Address
Street Address Address Line 2 City State ZIP Code
Employment Start Date
MM slash DD slash YYYY
Employment Start Date
MM slash DD slash YYYY
Reason for Leaving
Job Title
Immediate Supervisor
May we contact your employer?
- Yes
- No
Phone Number
Description of Duties
Have you received any disciplinary actions or were you terminated? If yes, please explain:
Employer/Company
Address
Street Address Address Line 2 City State ZIP Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Job Title
Immediate Supervisor
May we contact your employer?
- Yes
- No
Phone Number
Description of Duties
Have you received any disciplinary actions or were you terminated? If yes, please explain:
Employer/Company
Address
Street Address Address Line 2 City State ZIP Code
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Reason for Leaving
Job Title
Immediate Supervisor
May we contact your employer?
- Yes
- No
Phone Number
Description of Duties
Have you received any disciplinary actions or were you terminated? If yes, please explain:

EMPLOYMENT REFERENCES
Please complete the information below for three (3) business/work references, one of which must be a current or former supervisor or instructor. References must not be related to you. Providing this information means you give this organization permission to contact those individuals listed. When possible, please list an email address.
Reference Name
First Last
Business Relationship
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years Known
Phone Number
Reference Name
First Last
Business Relationship
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years Known
Phone Number
Reference Name
First Last
Business Relationship
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Years Known
Phone Number

Please read carefully prior to signing
This application is not complete until the following statement has been REVIEWED and SIGNED:
In compliance with federal and state equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, creed, religion, sex, ethnicity, national origin, alienage or citizenship, age, marital status, sexual orientation, physical or mental disability, service in the armed forces of the United States, or any other legally recognized protected classification under federal, state, or local laws, requirements or ordinances.

I hereby declare that the information provided by me in this Application for Employment (and in any accompanying resume) is true, correct and complete to the best of my knowledge. I understand that any omission or misrepresentation of facts on this application may result in rejection of my application and refusal to hire. I understand that if I am hired and any omission or misrepresentation is discovered after I begin employment with YCCAC, I may be terminated from employment. As an at-will employee, I understand that my employment may be terminated with or without cause, and with or without notice at any time, at the option of YCCAC or me. I understand that no management representative has any authority to enter into any agreement for continuing employment for any specific period of time or condition which is contrary to the foregoing without a written agreement signed by the Executive Director and myself. I authorize all individuals, schools and/or firms named herein (except my current employer, if so noted) to provide any information about me. I grant YCCAC the authority to verify any information presented on this application, on related papers and in interviews to conduct required background checks in connection with my application for employment. I release all liability from any persons, companies, corporations or educational institutions supplying such information. I also release YCCAC (or its designee) from any and all liability for claims resulting from the verification of such information.

I understand that any offer of employment is conditioned upon satisfactory completion of background checks. I understand that if I am hired the amount of time I am scheduled to work may be adjusted at the organization’s discretion. I understand this application is not a contract or an offer of employment.

My signature below attests to the fact that I have read, understand, and agree to be legally bound by all of the above.
Signature
First Last
Date
MM slash DD slash YYYY
To send us your resume once this application is complete, email us at apply@yccac.org with the subject "resume for :" and your name and attach your resume to the email.

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York County Community Action Corp.

York County Community Action Corp.

Employment Application

Job Application

EDUCATION / TRAINING (College Degrees Subject to Verification)

EMPLOYMENT HISTORY

EMPLOYMENT REFERENCES

Please read carefully prior to signing

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