Neighborhood House

Application for Employment

Neighborhood House is an equal opportunity employer and encourages applications from all persons. Auxiliary services are available upon request to individuals with disabilities. TDD/Washington Telecommunications Relay Service: 800.833.6384.

* indicates a required field

Instructions
Please read the job announcement relating to the position and provide all information requested.

	Position applying for:
*	Salutation:
*	First Name:
	Middle Name:
*	Last Name:
	Address:
	City:
	State:
	Zip:
	Tel (home):
	Tel (work):
	Tel (cell):
*	E-mail Address:
	How did you learn about this position?
	If Other, please indicate:

	Have you ever been employed by Neighborhood House? Yes No
	Still Employed?	Yes No
	Under what name?
	What location/position?
	Are you legally authorized to work in the United States? Yes No
	Have you been convicted of a crime, plead guilty or been released from prison within the past seven (7) years? Yes No
	If yes, indicate the date and nature of the offense:

Education

High School/GED
Name of School:
Location:
Diploma/Degree:

College
Name of School:
Location:
Dates Attended:
Diploma/Degree:

Graduate School
Name of School:
Location:
Dates Attended:
Diploma/Degree:

Other
Name of School:
Location:
Dates Attended:
Diploma/Degree:

Training
Name of School:
Location:
Dates Attended:
Diploma/Degree:

Experience & Skills

Typing:	wpm
Ten Key:	Yes No
Word Processing:	Yes No
Computer Experience:	Yes No
If yes, what programs?
Languages spoken fluently (other than English):
Please list other activities which have provided you with experience, training or skills which you feel would be helpful in a position with Neighborhood House:

Employment History

This section must be completed in detail. You may attach a resume, but a resume will not substitute for a completed application unless the job posting indicates. Beginning with your present or most recent employment, list your work experience for at least the last 10 years. Include periods of self-employment, U.S. military service, and any job-related volunteer experience. Be sure to list all jobs that relate to the position for which you are applying, no matter how long ago you worked in the position. If extra space is needed, please attach additional sheets.

Employment 1

Employer Name:
Phone:
Address:
May we contact this employer? Yes No
Position:
Dates employed (Mo./Yr.) From: To:
Supervisor:
Ending Pay: $ Per Full-time Part-time
Duties and Responsibilities:
Reason for leaving:

Employment 2

Employer Name:
Phone:
Address:
May we contact this employer? Yes No
Position:
Dates employed (Mo./Yr.) From: To:
Supervisor:
Ending Pay: $ Per Full-time Part-time
Duties and Responsibilities:
Reason for leaving:

Employment 3

Employer Name:
Phone:
Address:
May we contact this employer? Yes No
Position:
Dates employed (Mo./Yr.) From: To:
Supervisor:
Ending Pay: $ Per Full-time Part-time
Duties and Responsibilities:
Reason for leaving:

Employment 4

Employer Name:
Phone:
Address:
May we contact this employer? Yes No
Position:
Dates employed (Mo./Yr.) From: To:
Supervisor:
Ending Pay: $ Per Full-time Part-time
Duties and Responsibilities:
Reason for leaving:

Employment 5

Employer Name:
Phone:
Address:
May we contact this employer? Yes No
Position:
Dates employed (Mo./Yr.) From: To:
Supervisor:
Ending Pay: $ Per Full-time Part-time
Duties and Responsibilities:
Reason for leaving:

Give dates and explain all periods of unemployment during the last 10 years.

Drivers License

If stated as a requirement for this position, complete all data in this section.

State of current valid driver's license: Washington None Other:
License No:
Class/Type/Expiration:
If this position requires a State of Washington driver's license, answer the following: In the last five (5) years, has your license been suspended or revoked? Yes No
If Yes, list date revoked/suspended and reason:

Please list any tickets, accidents or moving violations in the last three (3) years:

Have you held a license in another state in the last three (3) years? Yes No
If Yes, provide license number and name (if different from your current license).
Name:
Number:
State:
Year(s):

References

List the names and current telephone numbers of three professional and at least one personal.

Professional
Name:
Organization:
Phone:

Professional
Name:
Organization:
Phone:

Professional
Name:
Organization:
Phone:

Personal
Name:
Organization:
Phone:

Personal
Name:
Organization:
Phone:

I certify that all statements on my application are true to the best of my knowledge. I authorize the agency to check the references provided and to pursue additional references if needed. I understand that employment at Neighborhood House is "at will," which means the employee or employer may terminate the employment relationship with or without cause at anytime. This application is not a contract of employment.

Application Data Sheet (voluntary survey)

Neighborhood House is an affirmative action / equal opportunity employer.

The following information is for purposes of obtaining data that will enable us to implement our Affirmative Action Plan. All information is confidential and any disclosure of your gender, ethnic group / race is voluntary. Refusal to provide or providing the information will not subject the applicant to any adverse treatment.

Position Title:
Last, First, Middle Name:
Gender:	Male Female

Ethnic Group/Race

1. Are you Hispanic or Latino?: Yes No (If yes, move to question 3)

2. Please check the box which best describes your race:

	African American / Black: A person having origins in any of the black racial groups of Africa.
	American Indian / Alaska Native: Persons having origins in the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition.
	Asian (Not Hispanic or Latino): A person having any of the original peoples of the Far East, Southeast Asia, and/or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
	Native Hawaiian or other Pacific Islander: A person having origins in any of the peoples of Hawaii, Guam, Samoa and other Pacific Islands.
	White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
	Two or more races: All persons who identify with more than one of the above (5) races.
	Other (Specification optional):

3. Do you meet the following disability definition? Yes No

A disability is a permanent physical, mental or sensory condition that substantially limits one or more of your major life activities. The disability must be substantial rather than slight, and permanent in that it is seldom fully corrected by medical replacement, therapy, or surgical means. "Substantially limits" means that you are either unable to perform or are significantly restricted in performing a major life activity, such as caring for yourself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working. This confidential information is solicited and maintained for affirmative action purposes only. It should not be construed and will not be considered as a request for accommodation.

Will you need accommodation in the application or testing process? Yes No

Individuals who indicate a "yes" response must make an accommodation request when contacted for an interview.

Are you a veteran?	Yes No
Dates Served:	to
Vietnam-Era Veteran?	Yes No
Special Disabled Veteran?	Yes No

Resume

We require that you either submit a resume by pasting it into the text box below or emailing it as an attachment as a Microsoft Word or Adobe PDF document to nhjobs@nhwa.org. Your application will be considered incomplete without this information.


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