From Roots to Wings

306 SW 146th Street

Burien, Washington 98166

Tel. (206) 246-7544 Fax: (206)246-1910

E-mail:

EMPLOYMENT APPLICATION

PERSONAL DATA Today’s Date /______/______/______

Name ______First Last

Address______

City______State______Zip Code______

Home Phone (______)______Cell Phone (______)______

Date of Birth______/______/______Social Security______

Email Address______

  1. Are you eligible to work in the United States? ______Yes ______No
  1. Have you been convicted of a felony in the past seven years? ______Yes ______No
  1. Are you able to perform the essential functions of your job? ______Yes ______No with or without accommodations?

If no, please explain why not______

EDUCATION

Name & Address of Institution / Major / Dates Attended / Degree / Credits Earned

Desired Position______Desired Salary$______

Please check if you have any of the following:

______Blood Borne Pathogens ______CPR/First Aid ______CPS Training ______TB

______Driver’s License ______Food Handler’s Card ______HIV/AIDS ______STARS 20 Hours

EMPLOYMENT HISTORY (Please start with most recent position)

Position______From /______/______/_____ To/______/______/_____

Company______

Address ______

City ______State ______Zip Code______

Supervisor ______Phone (______)______

Starting Salary______hour/month Ending Salary______hour/month

Reason for leaving______

Position______From /______/______/_____ To/______/______/_____

Company______

Address ______

City ______State ______Zip Code______

Supervisor ______Phone (______)______

Starting Salary______hour/month Ending Salary______hour/month

Reason for leaving______

Position______From /______/______/_____ To/______/______/_____

Company______

Address ______

City ______State ______Zip Code______

Supervisor ______Phone (______)______

Starting Salary______hour/month Ending Salary______hour/month

Reason for leaving______

(Pease attach an updated resume that describes your duties)

REFERENCES (List the name of two supervisors or people who have worked with and can provide a professional reference)

Name ______

First Last

Position Title ______

Company ______

Address ______City ______State ______Zip Code______

Work Phone (_____)______

Name ______

First Last

Position Title ______

Company ______

Address ______City ______State ______Zip Code______

Work Phone (_____)______

Note

In order for the application to be completed, a resume documenting education, experience, and responsibilities must accompany this contract and employment application.

Acknowledgment and Authorization

I attest that the information presented in this application for employment is complete, correct, and true to the best of my knowledge. I understand that consideration for employment and continuation of any employment gained as a result is dependent upon accurate and true representation of facts as presented in this employment application. Any falsification, misrepresentation, or omission of any information is grounds for immediate dismissal.

I understand that because I will be working with children, a criminal background investigation will be conducted and employment, or continued employment is contingent upon the results.

I hereby authorize From Roots to Wings to make inquiries regarding my education, experience, and references before offering me a position within the organization. I hereby release all parties and person associated with any inquiries regarding this employment application from liability in conjunction with the information they give, as long as the information is accurate and true. I understand employment is not permanent and is contingent upon agency contingency, funds, and performance, thus terminating at any time without prior notice.

Signature______Date /______/______/______

Print Name______

First Last

From Roots to Wings is an equal opportunity employer. We consider applications for all positions without regard to age, creed, ethnicity, gender, language, marital status, national origin, religion, physical disability, sexual orientation, veteran status, or any other legal protected status.

Hire Date: /______/______/______Position______

Starting Salary$______Start Date: /______/______/______