Employment Application

The Douglas Center is an equal employment opportunity employer, and a participant in affirmative action. The Douglas Center does not discriminate in hiring for employment on the basis of race, color, religion, national origin, gender, ancestry, marital status, parental status, military discharge status, source of income, sexual orientation, citizenship, disability or any other legally protected status. No question in this application is intended to secure information to be used for discrimination.

* indicates a required field

First Name * :     Last Name * :

Address * :     City * :

State*     Zip Code * :     Email * :

Phone * :     Alternate Phone * :

Date of Birth * :     Social Security Number:

Salary Expected $/hour * :    -OR-    $/year * :

Position Applied For * :

Comment

Recruitment*

How did you hear about The Douglas Center? (Please select one)

   Company Website

   Newspaper or Online Ad:    Source:

   Employee Referral:    Employee:

   Other:

Availability*

Full Time Part Time On Call

*Please indicate the times available below (i.e. 9am-4pm):

Education (Put N/A if not applicable)

Attended	Name/Address	Years Attended	Diploma/Degree Received
High School*
College/ University
Other

Personal/Professional References*

Please list 2 references that are familiar with your work and/or volunteer experience. (References should not be relatives):

Name	Relationship	Phone Number

Training/Skills

Training Certificates (i.e., CPR, First Aid, etc.)	Skills (i.e., computer programs, etc.)

Employment History

Please list employers starting with the most recent first.

Employer*

Address*     City*

State*     Zip Code*

Job Title*    Salary (per hour or per year) $

Supervisor's Name*

Phone*     Date Employed* to (mm/dd/yyyy)

Reason for Leaving*

May we contact this employer?* Yes     No

Employer

Address     City

State     Zip Code

Job Title    Salary (per hour or per year) $

Supervisor's Name

Phone     Date Employed to (mm/dd/yyyy)

Reason for Leaving

May we contact this employer? Yes     No

Please Read carefully and sign below

I understand that any false, misleading or incomplete statements made as part of this application or omission of information may be considered sufficient reason for immediate dismissal.

I authorize appropriate personnel of The Douglas Center to investigate my references and to make inquiries of courts and law enforcement agencies resulting from such investigations. Information furnished or recovered as a result of any inquiry will not necessarily preclude employment, but will be considered part of an overall evaluation of my qualifications.

I understand that nothing on the application is intended to create or imply a contractual relationship, if hired. I understand that the employment is at will and can be terminated with or without reason at any time. Only a written agreement signed by the President & Chief Executive Officer can change my status. Upon termination, I authorize the release of reference information on my work and I hold The Douglas Center harmless for the release of the information.

Applicant Signature (typed):