WOODWARD ACADEMY
EMPLOYMENT APPLICATION FORM

Position Applying For:
Name:
Street Address:
SSN:
Phone:
Email:
Are you 21 years of age or older? Yes   No
Is there a criminal charge pending against you? (Including DUI/DWI) Yes   No
If yes, give details:
Have you ever been convicted of, pled guilty, had prosecution deferred, or plead no contest, to a felony or misdemeanor or been a founded perpetrator in any incident(s) involving the mistreatment, molestation, abuse, neglect or exploitation of a child (or children)? Include convictions of DUI/DWI and driving with a suspended license. (Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offence, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense the position(s) applied for may, however, by considered.)
You are not required to disclose any erased, expunged, or pardoned convictions. Yes   No
If yes, when: Where:
Please explain circumstances:
Have you ever been employed by Sequel Youth and Family Services? Yes   No
If yes, give dates: -
Only U.S. Citizens or aliens who have the legal right to work in the United States are eligible for employment. If you are employed here, can you provide proof of your identity and legal right to work in the United States? Yes   No

MILITARTY SERVICE

Have you ever served in any branch of the United States military and/or reserves? Yes   No
If yes, Branch of Service:
Period of Active Duty:
Highest Rank Held:
Did you receive either a "bad conduct discharge" or "dishonorable discharge" from the military? Such a discharge will not necessarily disqualify you from the job for which you have applied. Yes   No
If yes, give details:

EDUCATION

Name of School
City/State
Did you graduate?
If no, # of years left to graduate
If yes, date of graduation
Degree type/Major
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Certification/Licensure
Please list all Professional Organizations and Associations:
Please list all Professional Certification and Licensure (organization, type, expiration):
Have you been subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions? Yes   No
If yes, please explain:

SKILLS/EXPERIENCE

Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert)

WORK HISTORY

Please list at least two previous employers even if you have provided a resume. Please take your time completing this section of the applicatoin. The information provided by you in this section will be used to qualify you for employment. Failure to do so will limit your ability for employment.

1. Most recent employer:

Employment Dates: -


May we contact his employer for a reference? Yes   No

2.

Employment Dates: -


May we contact his employer for a reference? Yes   No

3.

Employment Dates: -


May we contact his employer for a reference? Yes   No

EQUIVALENT WORK HISTORY SECTION


Indicate the specific job in your work history; equivalent to the position being applied for.
Your full completion of the application will be the basis for employment consideration.
Employment Dates: -


May we contact his employer for a reference? Yes   No
ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING, EITHER WITH/WITHOUT REASONABLE ACCOMMODATION? Yes   No
If no, describe the functions that cannot be performed (Note: Company complies with the ADA and consider reasonable accommodation measures that may be neccessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

REFERENCES


Please provide four professional references (i.e. Supervisors, Co-workers, Teachers, etc.)

1.


2.


3.


4.


ADDITIONAL INFORMATION

Which job status/shift would you accept? (Please check all that apply)
Full-Time
Part-Time
PRN/As Needed
Flex Time
Temporary
Day (7am-3pm)
Evening (3pm-11pm)
Day (11pm-7am)
Weekend
Carefully Read this Section Prior to Providing Acknowledgement Below.
I hereby affirm that information provided within this application, accompanying resume and all other supplemental information is true and complete. I acknowledge that any false or otherwise misleading representations or omissions made on said documents may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.
I understand that employment may be conditioned upon successfully passing a medical examination, and post-hire drug screen as a condition of employment. Additionally, I understand that a criminal background review and drivers motor vehicle report may be obtained to satisfy employment requirements.
I hereby authorize persons, schools, current employers, previous employers and organizations to provide Sequel Youth and Family Services and/or affiliates with any requested information pertaining to my application or suitability for employment. I release all such persons or entities from any and all liability related to the providing or use of such information.
I understand that my employment is at-will which means that I am free to terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any contrary agreement to the proceeding sentence, except for a written agreement signed by Sequel Youth and Family Services' Chief Executive Officer and notarized.
My typed name below shall have the same force and effect as my written signature.