Employment Application Form Page 4
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4Please list three recent work related references other than relatives
(Letters of recommendation with contact information may be attached if you prefer)
1. Name ___________________________________
Relationship __________________________________
Position _________________________________
Organization __________________________________
Address
_____ _
Telephone____________________________________
E-mail___________________________________
2. Name ___________________________________
Relationship __________________________________
Position _________________________________
Organization __________________________________
Address
_____ _
Telephone____________________________________
E-mail___________________________________
3. Name ___________________________________
Relationship __________________________________
Position _________________________________
Organization __________________________________
Address
_____ _
Telephone____________________________________
E-mail___________________________________
May we conduct a comprehensive reference check with those listed above?
Yes
May we also talk with colleagues not listed above that you are known to have worked with?
Yes
_ No, with the
xception of (please list):
e
Please contact
e f
rst
m
i
N
at this time
ot
Please read each paragraph, then sign below
I certify that I have not purposely withheld information that might adversely affect my chances for hiring. I attest to the fact
that
(including
the answers given by me are true & correct to the best of my knowledge and ability. I understand that any omission
any misstatement) of material on this application or on any document supplied can be grounds for rejection of the
application
or, if I am employed by this organization, terms for my immediate expulsion.
I am aware that a background check may be conducted as a part of considering my application. As noted above, I permit the
YWCA to examine my record of employment, education record and any other information I have provided. I authorize the
references I have listed to disclose any information related to my work record and my professional experiences with them
without giving me prior notice of such disclosure. In addition, I release the organization, my former employers and all other
persons, organizations, corporations, partners, collaborators and associations contacted from any and all claims, demands or
liabilities arising out of or in any way related to such examination or revelation.
Applicant's Signature _____________________________________ Date: ___________________________
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