Contact Information

Name*

First Last

Email*

Permanent Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone

Do you have the legal right to live and work in the U.S.?*

Yes
No

Employment Interests

Position(s) Desired or Area of Interest:*

After School Instructor
Camp Director
College Counselor

Why do you feel that you would be a good fit for the position you are applying for?

Date Available*

Type of Employment You Are Seeking:*

Part Time
Temporary

How were you referred to our organization?*

Name of Referral Source:

Have you ever applied to this organization before?*

Yes
No

If Yes, give date and position applied for

Have you ever been employed by this organization before?*

Yes
No

If yes, list dates of employment

Have you ever been convicted of a felony?*

Yes
No

If yes, list dates, offenses, and disposition.

Convictions are not an automatic disqualification from employment.

Have you ever been involved in an incident involving sexual or physical abuse of a child?*

Yes
No

Do you have any physical conditions or diseases that would affect your abilities to perform all camp and classroom duties?*

Yes
No

If yes, please explain*

What is your availability during the summer?

Education/U.S. Military Service

Where did you attend high school & college? (Click the + button to add a new row)*

School Name & Address	Major	Years Completed	GPA	Degree/Diploma

Are you taking any educational course(s) presently?*

Yes
No
I will be soon

If Yes or you will be soon, what and where?

Have you ever served in the U.S. Armed Services?

Yes
No

US Military Duties and special training

Rank held at discharge

References

List two professional references, at least one of which is a recent supervisor in a postion relevant to this position. (Include: name, relationship to you, email address and telephone number)

Name	Relationship	Email	Phone

Employment History

Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.

Company Name (Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Did you have another job before this one?*

Yes
No

Company Name (Second Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list another previous job?

Yes
No

Company Name (Third Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

Would you like to list a 4th job?

Yes
No

Company Name (Fourth Most Recent)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Dates Employed

From	To

Job Title

Supervisors Name & Title

Type of Business

Business Website

Base Rate of Pay (Hour/Week/Month)

Start	End

Description of duties

Reason for Leaving?

May we contact this employer?

Yes
No

I agree to a Drug Screening at the company's expense.*

Yes
No

I agree to a Criminal Background Check at the company's expense.*

Yes
No

Acknowledgement

To the best of my knowledge and belief, the information given truly represents my background and experience. I understand that if I have knowingly or negligently misrepresented, falsified or omitted any information during the application process, I may be disqualified for employment consideration or dismissed from employment with .

Digital Signature:

Printing your First Name + Middle Initial + Last Name will act as your digital signature.

Date

Resume Upload (optional)

Accepted file types: doc, docx, pages, odt, rtf, tex, txt, wpd, wps, pdf, Max. file size: 2 MB.

If you have a resume you'd like to attach, please do so here. This is not required.

Would you like to add a cover letter?

Yes
No

Cover Letter (optional)

Max. file size: 2 MB.

Please upload your cover letter here. You may also copy and paste the contents of your cover letter in the space below.

Instructor Application

Contact Information

Employment Interests

Education/U.S. Military Service

References

Employment History

Acknowledgement

Unearth a new discoveryAt Club Scientific