Camp Quaker Haven Summer Staff Application
Address_________________________________City___________________________
State_______________________ Zip code ____________________________________
Telephone___________________________
Date available to begin________________________
If previously employed by CQH, provide dates.______________________
Do you have special skills or talents that would be useful for this position?
________________________________________________________________________
Is there any reason that you might not be able to fulfill your responsibilities for
which you are applying? __________________________________________________
If you are offered a position, will you be able to verify that you are legally permitted
to be employed in the United States under Title VIII, U.S. Code Section 1324A,
either by providing U.S. citizen or permanent residence status or with unexpired
INS employment authorization?
Education
Please list highest level of education achieved________________________________
Institution______________________________________________________________
Employment History
Please list previous employment history starting with the most recent.
Employer______________________________ Position__________________________
Supervisor_____________________________ Phone ___________________________
May we contact this employer _______Yes _______ No
Duties __________________________________________________________________
________________________________________________________________________
Employer______________________________ Position__________________________
Supervisor_____________________________ Phone ___________________________
May we contact this employer _______Yes _______ No
Duties __________________________________________________________________
________________________________________________________________________
Employer______________________________ Position__________________________
Supervisor_____________________________ Phone ___________________________
May we contact this employer _______Yes _______ No
Duties __________________________________________________________________
________________________________________________________________________
References
Please list three professional references, none of whom may be a relative,
who have supervised or reviewed your work during prior employment
and whom we may contact:
Name___________________________ Position_________________________
Phone__________________________
Name___________________________ Position_________________________
Phone__________________________
Name___________________________ Position_________________________
Phone__________________________
Please list three character references, none of whom may be a relative,
who have known you for at least five years and whom we may contact:
Name_____________________________Occupation______________________
Phone_____________________________
Name_____________________________Occupation______________________
Phone_____________________________
Name_____________________________Occupation______________________
Phone_____________________________
Verification
I understand that if I am employed and if any statement herein is not true, I may be released immediately. If I am released, I will be paid only through the day of release.
I understand that if employed, I will be required to abide by all company policies, standards and regulations, as they promulgated from time to time. I further understand that if employed, when my employment is terminated by retirement or otherwise, I must return all of employment's property in my custody before I am entitled to final payment of any amounts due me on separation.
I hereby authorize Employer to contact all prior employers and any references listed herein to verify all information provided and to obtain any and all information related to my character and past work performance. I further hereby release all references and prior employers from any liability for information provided in good faith.
I hereby affirm that I have carefully read and agree with Employer's Statement of Faith, a copy of which was furnished to me in connection with this application form. I understand that if at any time subsequent to employment I no longer agree with Employer's Statement of Faith or exhibit conduct which is contrary to the Statement of Faith, or I fail to meet the minimum requirements of the position, I may be disqualified from employment.
I affirm that I have neither been convicted of, nor am I subject of pending charges for, any offense involving actual or attempted child abuse or sexual molestation in any jurisdiction.
I recognize that as a condition of my employment, I may be required to consent to furnish to Employer a criminal records check from the Central Criminal Records Exchange or other appropriate federal and/ or state law enforcement agency, and I consent to do so, realizing the importance of promoting Employer's ability to protect its workers and those whom it services.
I understand that this is an application for employment and that no employment contract is being offered.
I hereby affirm and acknowledge, by signing below, that all the information provided and all of my answers to the forgoing questions are true and complete, and that any misrepresentation or omission may be grounds for rejection or, if later employed, dismissal.
_____________________________________________________ _______________
Applicant's Signature Date
Return to
Camp Quaker Haven
8438 312th Road