Name
	Last First Middle

Present Address
	Street City State Zip

Permanent Address
	Street City State Zip

Have you ever been employed at the Beaver County YMCA?

Yes No

If yes, when and for what position

Education

Level	Name and Address	No. Years Attended	Did you graduate?	Major/Degree
High School
College
College
Other

What other special training certifications or special qualifications do you hold?

Have you ever been convicted of a crime in the last seven (7) years?

Yes No

If yes, please explain.

Previous Employment (Start with most recent employee)

Month and Year	Name and Address of employer	Wage	Position	Reason for leaving
From To
From To
From To
From To

References (List three references that are not family members)

Name	Address	Relationship	Phone (with area code)

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 listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand and agree that if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.