Online Employment Application Form

Investing in our future

Online Employment Application Form
Tumbleweed Center For Youth Development is
An Equal Opportunity Employer
If your application does not provide the information requested,
you may lose consideration for employment.

Top of Form

PERSONAL INFORMATION

Name: (Last name first)	Social Security Number:
Mailing Address:	City:	State:	Zip code:
Phone Number:	Email Address:
Are you 18 yrs or older? Yes No

EMPLOYMENT INFORMATION

WORK EXPERIENCE

Present or last Employer:		Name:
		Address:

Job Title:

Starting Date:

Leaving Date:

Salary:

Hours Per Week:

Supervisors Name:

Supervisors Phone Number:

May We Contact Your Current Supervisor?
Yes No
If we need to contact your supervisor before making an offer, we will contact you first.

Describe Your Duties and Accomplishments

WORK EXPERIENCE

Employer's Name and Address:		Name:
		Address:

Job Title:

Starting Date:

Leaving Date:

Salary:

Hours Per Week:

Supervisors Name:

Supervisors Phone Number:

Reason For Leaving:

Describe Your Duties and Accomplishments

WORK EXPERIENCE

Employer's Name and Address:		Name:
		Address:

Job Title:

Starting Date:

Leaving Date:

Salary:

Hours Per Week:

Supervisors Name:

Supervisors Phone Number:

Reason For Leaving:

Describe Your Duties and Accomplishments

WORK EXPERIENCE

Employer's Name and Address:		Name:
		Address:

Job Title:

Starting Date:

Leaving Date:

Salary:

Hours Per Week:

Supervisors Name:

Supervisors Phone Number:

Reason For Leaving:

Describe Your Duties and Accomplishments

EDUCATION

OTHER QUALIFICATIONS

Job-related training courses (give title and year). Job related skills (other languages, computer software/hardware, typing etc.). Job-related certificates and licenses (current only). Job-related honors, awards, and special accomplishments (publications, memberships in professional/honor societies, leadership activities, public speaking, and performance awards. Give dates, but do not attach documents unless requested.

REFERENCES:
Three Persons Who You Are Not Related To, Whom You Have Known At Least One Year

Name	Address	Business	Phone Number	Years Acquainted

HAVE YOU BEEN CONVICTED OF A FELONY OR MISDEMEANOR? Yes No

If Yes, Please Explain:

AUTHORIZATION
“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED; FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE AND RELEASE THE COMPANY FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.

I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF THE COMPANY HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED COMPANY REPRESENTATIVE”.

By Checking This Box, You Signify That You Are in Agreement With The Authorization Clause Above. You Also Agree That This Check Mark Is Legal and Binding in Place of Your Signature.

YOUTH CARE/OUTREACH WORKER SUPPLEMENTAL QUESTIONNAIRE
*COMPLETE THIS SECTION ONLY IF YOU ARE APPLYING FOR THE POSITION(S) ABOVE

1. Please outline your experience of working with (supervising) youth with a brief explanation as to your reason for applying for the Youth Care or Outreach Worker position.

2. How would you respond to a youth who used abusive language?

3. What can you contribute to establish a positive working environment at Tumbleweed?

4. What qualities do you have that make you an effective team player?

5. Are you familiar with the Youth Development Model? If so, briefly explain.