Comp Stoff Applicotion

Comp Stoff Applicotion
Form 3
Reiurn lo:
Developed by Americon Comp Associofion@
(Pleose lype
or print.)
Dote o{ Applicotion
Sociol Security Number
Nome
Permonenl Address
zip
Slreel & Number
Fox-
Phone-
E-moil
Areo & Number
Areo & Number
School or Business Address
Street
Phone
E-moil
Fo
Areo & Number
Areo & Number
Dotes ovoiloble
Ci,
& Number
From
To
Whot type of position do you wonl ol comp?
Solory desired?
Do you meet or exceed ony minimum oge requirements for thot
position?
[
Don't know minimum oge
IYes E N"
Con you perform lhe essentiol functions of the lob for which you hove opplied,
with or without reosonoble occommodotion?
flYes
flNo
lf you ore hired would you desire or need housing {or ony person(s) other lhon yoursel{ ot the comp?
flYes
n
PostWorkHistory Provideo{ull recordof oll employmenl-poidondvolunleer-ondexploinonygopsinemployment.
No
lnclude
ony positions on comp stoff. Use o seporoie sheet, i{ necessory.
Doles
Employer/Supervisor
Address & Phone
Noture of Work Reoson for Leoving
lndicoie ony employer you do not wish us to contocl, ond the reoson
This {orm hos been drofted to comply with federol employment lows; however, ACA ossumes no responsibility
OmefiCOn 4lqVOtSOCiOtiOnt
or liobilily {orlhe use o{ihis {orm.
copyrishrlgTgbyAmericoncompinsAssociorion,tnc.Revisedlggo,
1991, 1992,1994,1996,1998,1999,2004,2007, 201 3
References Give nomes ond oddresses o{ three persons [not relotives] hoving knowledge o{ your chorocter, experience, work
hobits, ond obility.
Address & City
Nome
Phone
Comp Experience
Dotes
Comp & Direclor
Locolion
Comper or Stoff?
Educolion High School ond Beyond
Yeors
School
Moior Subjecis
Degree Gronted
Write o brie{ biogrophicol sketch, including speciolized troining in comping, ond experience or troining in other fields whlch might
hove o beoring on the position(s) for which you ore opplying. Attoch o seporote sheet i{ necessory.
Comp Progrom Skills ln the {ollowing list, put o "T" before those octiviiies you con orgonize ond teoch os on expert, ond
on "A' for those octivities in which you con ossist. Put o "C" o{ter lhose in which you hove currenl certificotion ond ottoch o
copy o{ your certiiicotion.
Adventure/Chollenge
_
_
_
Donce (list)
chollenge/ropes course
climbtng/roppelling
spelunking/coving
Dromo
_
_
Arts/Crofls
_
_
_
_
_
clowning
Woterfront Activities
_
_
_
_
_
_
_
oerobics/exercise
orchery
boseboll/softboll
bosketboll
bicycling/biking
theoier
boxing
_
-_
_
ceromics/pottery
drowing/pointing
leoiher crofl
Sports/Fitness
_
_
_
_
_
Music
metol work
singing
photogrophy
instrumenl {lisl)
woodworking
{encing
{ishing
diving
koyoking
rofting
rowing
soiling
SCUBA
{ootboll
_
-_
gol{
_
-_
boord soiling/wind surfing
conoeing
gymnostics
swimming
synchronized swimming
woler skiing
hockey (icelin-line)
horsebock riding (English)
Compcrof/Pioneering
Nolure
bockpocking
_
_
_
_
compcrofl
outdoor cooking
outdoor living skills
_
_
overnights
wilderness lrips
Miscelloneous
informol gomes
_
_
_
_
modiol orts
_
_
onimols/onimol core
birds
soccer
_
_
_
_
_
environmentol studies
snow sporis (lisl)
oslronomy
hiking
orienteering
_
_
_
_
horsebock riding [Western)
ri{lery
sko'ling (ice, roller, in-line)
insects
rocks/minerols
weolher
oviotion
community service
iorming/ronching/gordening
{oreign longuoge
_
{lowers
{orestry
ocodemics
leodership developmeni/ClT
rodio/TVlvideo
_
_
_
_
tennis
trocV{ield
_
_
volleyboll
storytelling
teom building
worehip seruices/religious s.iudies
wrestling
Skills ln the following list, pleose check ihose items in which you hove experience
ond skills. Mork with o "C" those for which you hold curreni certiiicotion ond ottoch o copy of your certificotion.
Certificotions ond Comp Support Sloff
Business/Administrotion
_
-
Heolth/Sofety
bookkeeping/occounting
compulerlechnicol
Moinienonce
CPR
{irst oid
compuler/so{twore {list)
_
oulo
_
li{eguord
nursing
Food Seryice
mechonics
cooking/meol preporotion
corpenlry
Food Hondler's Pemii/Certif icotion
menu plonning
electricol
_
plumbing
_
purchosing
sonilolion
Answer these questions
onti{
Do you hove o volid driver's
opplying {or o position requiring driving
license?
Do you hove current chouffeur's-iype
Do you hove o commerciol driver's
license?
license?
nYes E
No
EYes ENo
EYes ENo
Stote
Whot coniributions do you think you con moke oi comp?
Whot contributions do you think o well-run comp con moke to children?
Horossment The comp's policy is to prohibit oll forms of horossment by our employees. This includes sexuol, rociol, religious,
ond other forms of horossment. Hove you ever been occused o{ horossmeni of ony person including, but not limited to, workploce
horossment? (Note: o prioroccusotion is noton outomotic borto employment. Thetype of occusolion ond when itoccurred will be
E Yes n No
evoluoled by ihe comp before ony decision is mode.)
Exploin
o crime, other thon o minor troffic offense? li yes, pleose describe. (Note: o
prior conviction is not on outomotic bor 1o employment The type o{ conviction ond when it occurred will be evoluoted by the comp
Criminol Record Hove you ever been convicted oi
EYes
before ony decision is mode.)
nNo
Exploin
I ouihorize investigolion of oll stotements herein, including ony checks of criminol records, ond releose the comp ond oll others
{rom liobllity in connection wilh some. I understond ihoi , if employed, I will be on ot-will employee unless ihere is on ogreement
or low which olters thol stotus. Furthermore, I understond thot ony ogreement must be in writing ond signed by the designoted
comp officiol. I olso underslond thol misrepresentotions or folsi{icotlons herein or in oiher documenis compleied or submitted
by the opplicont wlll resuh in dismissol, regordless of the dote of discovery by ihe comp.
Signoture
A// sloiements become pori o{ ony future employee personne/ files.
Dote