Colonial Club Senior Activity Center
Application For Employment

Employment Application Date:  : 

Personal Information

Social Security Number: 

Last Name:   

First Name:  

Middle Name: 

Present Address:
Street:        

City:                       State:               Zip:  

Permanent Address:
Street:        

City:                       State:               Zip:  

Home Phone:            Fax:      Cell:       Private Email: 

State Name(s) of any Relative(s) working for Colonial Club Senior Activity Center:

Please tell us how you learned about Colonial Club or who referred you:

 

Employment Objective:

Position Desired:         Date Available for Work:          Salary Desired:

Are there any restrictions on your availability to attend work on a regular basis and/or work overtime?:  

Have you ever applied for a position at the Colonial Club before?: Yes  No  

If so, when?   Were you offered employment?

Education and Training:

Level

Name of School

Location (City,St)

Number of Years Completed

Degree and Date

High School

College(s)

Graduate Work

Other Schools


Major Course(s) of Study:   Minor Course(s) of Study:

Former Employers:

Are you employed now?: Yes    No      If so, may we contact your present employer?: Yes    No  

(Please show most recent employer first)

Employer 1

Name of Employer:  City:   State:   Zip:

From (mo/yr):  To (mo/yr):    Beginning Monthly/Hourly Compensation:  
Ending Monthly/Hourly Compensation: 

 Job Title:    Immediate Supervisor:    Phone #: 

Full name while employed:   Job Duties:

Did you voluntarily terminate your employement?: Yes    No

Reason for leaving:

Employer 2

Name of Employer:  City:   State:   Zip:

From (mo/yr):  To (mo/yr):    Beginning Monthly/Hourly Compensation:  
Ending Monthly/Hourly Compensation: 

 Job Title:    Immediate Supervisor:    Phone #: 

Full name while employed:   Job Duties:

Did you voluntarily terminate your employement?: Yes    No

Reason for leaving:

Employer 3

Name of Employer:  City:   State:   Zip:

From (mo/yr):  To (mo/yr):    Beginning Monthly/Hourly Compensation:  
Ending Monthly/Hourly Compensation: 

 Job Title:    Immediate Supervisor:    Phone #: 

Full name while employed:   Job Duties:

Did you voluntarily terminate your employement?: Yes    No

Reason for leaving:

Specialized Skills and Knowledge:

List any achievements or activities that you consider relevant to your ability to perform the job for which you are applying, such as: awards received, memberships or offices held in professional organizations, licenses held, computer languages or software programs, foreign languages (proficiency in speaking and writing), etc.

References:

Please provide the names of three people (not related to you ) we may contact, whom you have known at least one year.

Name

Address

Relationship

Phone Number

Years Acquainted


In case of emergency notify:
Name:   Phone Number 1:    Phone Number 2: 

I understand and acknowledge the following:

1.    I authorize investigation of all statements contained in this application and any supporting documents.  I authorize Colonial Club to secure information about my experience from former employers, educational institutions, government agencies, or any references I have provided, and for those parties to provide information concerning my qualifications for employment, and I hereby release all parties from any liability arising from such investigation.

2.    I understand that if I am employed, any false statement, misrepresentation, or omission of facts on this application or on any supporting documents, regardless of when discovered to be false, may result in my immediate dismissal.

3.    My signature below certifies that I have read, understand, and agree to the foregoing and to the best of my knowledge and belief, the information on the application form is true and correct.



Date:    Your typed name here represents your signature:



Colonial Club Senior Activity Center is an equal opportunity employer.
Please contact the Executive Director if you have any questions or complaints regarding this policy. 

Please submit the completed application and a copy of your resume to: 

Colonial Club Senior Activity Center
301 Blankenheim Lane
Sun Prairie, WI  53590

Please fill out the following voluntary self-identification/disclosure form if you want to.  Whether or not you do, you MUST click the SEND THE INFORMATION button at the bottom of the page in order to send ALL the information you provided in either or both forms.

 

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Colonial Club Senior Activity Center

Self-identification/Disclosure Form

Name:

Address:

Contact Information:

Desired Position:

In an attempt to determine the effectiveness of our recruitment efforts, we request that you Voluntarily provide the following information.

Sex:

Male:   Female:   Other(please indicate):

Race/Ethnicity/Cultural Identity:

   African American/Black
   Latino/Latina
   Asian/Pacific Islander
   American Indian/Native American/Alaskan Native
   White/Caucasian
   Multi-racial
   Other (Please indicate):

How did you find out about this position?:

   Newspaper
   Website
   Relative/friend/acquaintance
   Other

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This form uses Huggins' Email Form Script

 revised 03/02/09