Yakima Neighborhood Health Services

Application for Employment

Personal Information:

Name	DOB:
Email Address:	Social Security #
Address	Phone#
Will visa or immigration status prevent lawful employment?	Yes No
If under age 18, can you provide proof of eligibility to work?	Yes No
During the last 7 years, have you been convicted of any criminal offense involving violent behavior, dishonesty, or breech of trust? If yes, explain:	Yes No

Employment Desired:

Date Available	Position/Job Desired:
Days Available to Work (circle )	Mon Tues Wed Thurs Fri Sat
Hours Available (circle)	Mornings afternoons evenings
Employment desired:	Full-time Part-time Other (explain)
Is there anything that would prevent you from coming to work on a regular basis during the next 12 months?	No    Yes explain:

Education:

	High School	College	Trade / Other
Name / Location of School
Dates Attended
Did you graduate?
Major area of study
Degree obtained
Date of degree

We are required to verify the following information. Please provide copies, along with contact information:

· Verification of completion of highest degree obtained

· Verification of certification of special training

· Verification of other competencies appropriate to serving low income and disadvantaged individuals and families.

Job Performance Ability:

Are you able to perform on a regular basis all the essential functions of the job for which you are applying, with or without reasonable accommodation?  Yes   No

Please describe any accommodation required:

Work History (list most recent employer first. Include employment that covers the last 7 years. Explain any periods of unemployment more than 30 days):

Employer	Date Hired
Address	Date Separated
Name/Title of Supervisor	Phone
Your title / responsibilities	Starting wage
Reason for leaving:	Ending wage:

Employer	Date Hired
Address	Date Separated
Name / title of Supervisor	Phone
Your title / responsibilities	Starting wage
Reason for leaving:	Ending wage

Employer	Date Hired
Address	Date Separated
Name / Title of Supervisor	Phone
Your title / responsibilities	Starting wage
Reason for leaving:	Ending wage

Employer	Date Hired
Address	Date Separated
Name / Title of Supervisor	Phone
Your title / responsibilities	Starting wage
Reason for leaving:	Ending wage

Professional Registration / Licensure (attach copies):

Type of Registration/License

State

Number

Expiration Date

If you do not have a required registration or license, have you applied for one? Yes No

If an exam is required, what date are you schedule to take the exam? _______________

If not licensed in Washington State, have you applied for reciprocity? _______________

Occupational Skills / Experience:

Do you speak any languages other than English?

If so, are you certified by any agency?

List any additional skills or training , or any additional information about your work habits / experience you would like us to know about:

Describe your computer skills:

References: List three professional references, who can discuss your work abilities:

Name

Address

Phone

relationship

List any current or former employees of YNHS you know :

________________________________________________________________

Your signature below:

1. 1. Certifies the information provided on this application is true and complete. Any misrepresentations may result in rejection from employment or termination if hired.

2. 2. You authorize former employers, schools, and references to provide information about your skills and abilities to YNHS.

3. 3. You authorize YNHS to conduct an inquiry of the Washington State Patrol. This inquiry provides information of convictions of crimes against children or other persons, crimes relating to drugs, crimes relating to financial exploitation of a vulnerable adult, and certain civil adjudications.

_______________________________________________________________

Applicant’s Signature Date

APPLICANTS DO NOT WRITE BELOW THIS LINE