United Way of Santa Barbara County Job Application

320 E. Gutierrez Street
Santa Barbara, CA 93101
Tel 805-965-8591
Fax 805-962-3461
www.unitedwaysb.org

Employment Application
An Equal Opportunity Employer

Please read the entire form before you begin filling it out and answer all questions, indicating "None" where applicable. Answers should be typed, printed or carefully written in ink so that they are clear and readable. This application must be completed in its entirety before any offer of employment may be considered. Resumes will not be accepted in lieu of any information required on this form. United Way of Santa Barbara County observes all Federal and State law and regulations related to discrimination in employment.

A. Personal Information
Date
1. Full Name:
2. Business Telephone (with Area Code)
3. Home Telephone (with Area Code)
4. Mobile Telephone (with Area Code)
5. Email Address
6. Social Security Number
7. Drivers License Number
8. Present Address
9. Permanent Address (if different from present address)
B. Employment Desired
1. Position Applying for
2. Are You Applying for	Regular Full Time Work Regular Part Time Work Temporary Work (Campaign Executive or Special Projects
3. What Days and Hours are you Available for Work?
4. If Applying for Temporary Work, During What Period of Time Will you be Available?
5. Are you Available to Work on Weekends?	Yes No
6. Would you be able to Work Overtime if Necessary?	Yes No
7. If Hired, on What Date can you Start Work?
8. Salary Desired
C. Background Information
1. Have you ever Applied or Worked for United Way of Santa Barbara County?	Yes No
2. If Yes, When?
3. Do you have any Friends or Relatives Working for United Way of Santa Barbara County?	Yes No
4. If Yes, State Name(s) and Relationship
5. Why are you Applying for Work at United Way of Santa Barbara County?
6. If Hired, Would you Have a Reliable and Insured Means of Transportation to and from Work?	Yes No
7. Are you at Least 18 Years Old? (If under 18, hire is subject to verification that you are of minimum legal age)	Yes No
8. If Hired, can you Present Evidence of your U.S. Citizenship or Proof of Your Legal Right to Live and Work in this Country?	Yes No
9. Are you Able to Perform the Essential Functions of the Job for Which you are Applying?	Yes No
If No, Describe the Essential Functions that Cannot be Performed Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions
8. Are you Able to Perform all Other Duties of the Job for Which you are Applying?	Yes No
If no, Describe the Functions that Cannot be Performed/All Other Duties Note: Hire may be subject to passing a medical examination, and skill and agility tests
9. Have You Ever Been Convicted of a Criminal Offense (felony or serious misdemeanor)? (Convictions for marijuana related offenses that are more than 2 years old need not be listed)	Yes No
If Yes, State the Nature of the Crime(s), When and Where Convicted and Disposition of Case Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered
10. Are you Currently Employed?	Yes No
If so, May we Contact Your Employer?	Yes No
D. Work Relationships
1. How would you describe the type of relationship you should have with your supervisor?
2. How would you describe the type of relationship you should have with your subordinates?
3. Briefly describe both the best and worst supervisor to whom you have reported in the past.
4. What would you do if the president of the company asked you to do something that your supervisor had specifically asked you not to do?
E. Problem Solving
1. Describe a challenge you met in a previous job, and what you did to meet that challenge.
2. Describe a mistake you made in a previous job, and what you did to correct it.
3. If you had been out of the office for several days, how would you prioritize the work to be caught up on when you returned?
F. Work History-List in Descending Order, Most Current First
1. Name of Employer
a. Employer Address
b. Type of Business
c. Telephone Number
d. Your Supervisor's Name
e. Your Position and Duties
f. Date of Employment	From: To:
g. Weekly Pay	Starting: Ending:
h. Reason for Leaving
2. Name of Employer
a. Employer Address
b. Type of Business
c. Telephone Number
d. Your Supervisor's Name
e. Your Position and Duties
f. Date of Employment	From: To:
g. Weekly Pay	Starting: Ending:
h. Reason for Leaving
3. Name of Employer
a. Employer Address
b. Type of Business
c. Telephone Number
d. Your Supervisor's Name
e. Your Position and Duties
f. Date of Employment	From: To:
g. Weekly Pay	Starting: Ending:
h. Reason for Leaving
4. Name of Employer
a. Employer Address
b. Type of Business
c. Telephone Number
d. Your Supervisor's Name
e. Your Position and Duties
f. Date of Employment	From: To:
g. Weekly Pay	Starting: Ending:
h. Reason for Leaving
Give any information you may wish covering your qualifications, licenses, certificates, or interests pertinent to the job for which you are applying. Include any courses or training which may be applicable.
Typing Yes No WPM Date Last Tested

Computer Software: MS Word MS Access Word Perfect MS Publisher MS Excel MS Powerpoint Other
Other Skills: Adding Machine Switchboard Cashier Translation Data Entry Other
Professional License/Certification & Number
State Issued Date Issued Expiration Date
State Issued Date Issued Expiration Date
Please list any languages, other than English, that you are familiar with: Language Read Spoken Written Language Read Spoken Written
G. Military Service
1. Have you obtained any special skills or abilities as the result of service in the military? Yes No If yes, please describe
H. References
List below three persons not related to you who have knowledge of your work performance within the last three years.
1. Name Address Occupation Telephone Number Number of Years Acquainted
2. Name Address Occupation Telephone Number Number of Years Acquainted
3. Name Address Occupation Telephone Number Number of Years Acquainted
J. Please Read Carefully, Initial Each Paragraph and Sign Below
Initials	I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
Initials	I hereby authorize the company to thoroughly investigate my references, credit, work record, education and other matters related to suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
Initials	I understand that nothing contained in the application, or conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between the company and me. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.
Initials	I hereby agree to submit to binding arbitration all disputes and claims arising out of the submission of this application. I further agree, in the event that I am hired by the company, that all disputes that cannot be resolved by informal internal resolution which might arise out of my employment with the company, whether during or after that employment, will be submitted to binding arbitration. I agree that such arbitration shall be conducted under the rules of the American Arbitration Association. This application contains the entire agreement between the parties with regard to dispute resolution, and there are no other agreements as to dispute resolution, either oral or written.
Date	Applicant's Signature

First Name: Middle Name/Initial: Last Name:
Home Address:
City County State Zip
Social Security Number Drivers License or State Id State Issued
For Identification Purposes, please provide full date of birth:
Have You Used any Names or Social Security Numbers Other than Above? Yes No
Please list other names used:
Please list other social security numbers used:
Please Sign: Signature Authorizing the Procurement of the Consumer Report and/or Investigative Report
Today's Date: