Position Desired:
Are you Seeking:		Full Time Part Time
If part time, hours desired:
Date available to start:
Salary Desired:
Personal Information
Last Name:
First Name:
Middle Initial:
Address:
City:
State:		- Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
ZIP Code:
Home Phone:		( ) -
Cell Phone:		( ) -
E-Mail Address:
If under 18 yrs of age, can you provide proof of eligability to work?:		Yes No
Are you legally eligible for employment in the United States?:		Yes No
Education
Education:		- Select One -High SchoolTechnical SchoolCollegeGraduate School
Name and Location:
Years Completed:
Degree/Diploma:
Education:		- Select One -High SchoolTechnical SchoolCollegeGraduate School
Name and Location:
Years Completed:
Degree/Diploma:
Have you ever been convicted of a crime in the past 10 years?:		No Yes
References
List three (3) work-related or personal references.:
Do you hold current CPR certification?:		No Yes
Do you hold current first aid certification?:		No Yes
Do you hold current lifeguarding certification?:		No Yes
Work Experience
Company Name 1:
Phone:		( ) -
Employment Dates:
Supervisor:
Job Title/Description:
Weekly Pay:
Company Name 2:
Phone:		( ) -
Employment Dates:
Supervisor:
Job Title/Description:
Weekly Pay:
PLEASE READ CAREFULLY BEFORE SIGNING Applicant’s Agreement and Release I certify that all the information provided by me in support of my application for employment is true and correct to the best of my knowledge. I understand that misrepresentations or omissions may be cause for rejection or for subsequent dismissal if I am hired. I hereby authorize any former employer, person, firm, corporation or government agency to answer any and all questions and to release or provide any information within their knowledge of records. I agree to hold any or all them blameless and free of any liability for releasing any truthful information that is within knowledge of records. The YMCA of Central Massachusetts is hereby authorized to release to any other firm or person with whom I may seek employment, any and all information concerning my application or employment. It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits. I understand and agree that if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or the YMCA of Central Massachusetts. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of the YMCA of Central Massachusetts.

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