CHARIS YOUTH CENTER
714 W. Main St · Grass Valley, CA 95945
(530) 477-9800 · Fax (530) 477-9803
Employment Application

Personal Information  
Last Name
 
First Name
 
Middle Name
 
Street Address
 
City
 
State
 
Zip Code
 
Phone
 
Other names you have had
 
     
Position Desired
   
Job Title
 
Desired Salary
 
Date Available
 
Type of Employment
  Full-Time
On Call		 Part-Time
Internship
Have you ever applied before?
  Yes No
If yes, give date
 
What prompted your
application to our company?
  Advertisment
Agency
 Referral
Other
 
   
Personal History
   
Date of First Aid Card
 
Date of Last Physical Exam
 
Date of Last TB
 
Name of Nearest
Living Relative
 
Relative's Telephone Number
 
Relationship with Relative
 
     
Education and Training    
     
High School
   
 
Name
 
 
Location
 
 
Date Attended From
 
 
Date Attended To
 
 
Major
 
 
Degree
 
 
Date of Degree
 
     
College / University
   
 
Name
 
 
Location
 
 
Date Attended From
 
 
Date Attended To
 
 
Major
 
 
Degree
 
 
Date of Degree
 
     
Post Graduate
   
 
Name
 
 
Location
 
 
Date Attended From
 
 
Date Attended To
 
 
Major
 
 
Degree
 
 
Date of Degree
 
     
List other job-related training,
schoolastic honors,
prefessional licenses,
certifications or credentials		  
     
Experience    
     
Most Recent Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
Previous Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
Previous Employer
   
 
Company
 
 
Company (cont.)
 
 
Address
 
 
Address (cont.)
 
 
Supervisor's Name
 
 
Phone Number
 
 
May we Contact?
  Yes No
 
Your Job Title
 
 
Date Employed From
 
 
Date Employed To
 
 
Reason for Leaving
 
     
References    
     
Reference 1
   
Name
 
Phone Number
 
Relationship
 
     
Reference 2
   
Name
 
Phone Number
 
Relationship
 
     
Reference 3
   
Name
 
Phone Number
 
Relationship
 
     
Other    
Are you 21 years
old or over?		   Yes No
Can you submit verification
of your identity and legal
right to work in the United
States?		   Yes No
Have you ever been
convicted of a crime?
(Exclude any minor traffic
volations for which the fine
was $50.00 or less.)		   Yes No
Do you currently have a
valid driver's license?		   Yes No
Has your driver's license
ever been suspended or
revoked, or have you
received more than one
moving violation in the
last three years?		   Yes No
Do you have any physical
condition which may limit
your ability to perform the
job applied for?		   Yes No
     
Employee Availability    
I understand that availability to work assigned schedules is an
important consideration for Charis Youth Center during the
hiring process and therefore, I now state that, if hired, I am
available to work as follows:
     
    From To
Monday  
Tuesday  
Wednesday  
Thursday  
Friday  
Saturday  
Sunday  
     
I certify that all statements are true, and I give permission for
necessary verification.
     
Input the text you see in the image above: