Employment Application Form Employment Application Step 1 of 9 11% Please read the following prior to completing this application: Equal Employment Opportunity The Yavapai Humane Society (YHS) is committed to providing equal employment opportunities and a workplace free from unlawful discrimination or harassment of employees or applicants on the basis of race, religion, color, national origin, disability, age, sex, sexual orientation, marital status, availability for military service, or any other basis prohibited by federal, state or local law. Accuracy and completeness of this form are important factors in determining acceptability for employment with YHS. Please be neat in completing this form and do so in your own handwriting or you may visit our website, www.yavapaihumane.org and fill out an electronic version. If you desire any assistance, please ask one of the Customer Service Associates at the front office or call 928-445-2666. You may be requested to submit additional references, participate in additional interviews and supply needed information. All pre-employment inquiries are made for the purpose of establishing your qualifications for employment with the Yavapai Humane Society. Your application will receive full evaluation and you will be considered in competition with other applicants for any vacant position for which you qualify. Completion of this application does not assure employment. Conditions Related to Employment with YHS • Drug and Alcohol Testing – The Yavapai Humane Society conducts pre-employment screening for illegal drugs. All offers of employment will be contingent on such screening and failure to pass the required test(s) will result in any employment offer with YHS being rescinded. If hired, you may be asked to submit to random, periodic testing for illegal drugs or testing for alcohol impairment or the presence of illegal drugs upon reasonable suspicion. This will be a condition of continued employment. Refusal to submit to an alcohol or drug screen will be cause for termination. • Background Check – If offered employment with YHS, you will also be required, as a condition of the employment offer, to agree to a background check with the state of Arizona Judicial Branch Public Access (specifically court information and a case search). You will be asked to supply picture identification which includes your birth date in order for YHS to conduct the background check. Note: A conviction of a crime will not be an absolute disqualification to employment. • Identity/Ability to Work – If offered employment with YHS, you will be required, as a condition of the employment offer, to submit proof of identity and legal right to work in the United States before your first day of employment. You must be able to comply with Federal I-9 laws as well as be approved through E-Verify. • Driver’s License – If the position applied for requires driving on the job, you will be required to possess a current and valid Arizona driver’s license. Any offer of employment in which the position requires you to drive is contingent on your ability to be adequately covered by YHS’s auto insurance company.I have read the above terms and agree to them* I have read the above terms I have not read the above terms Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Mobile Phone*Email* Is there additional information relative to a change of name, use of an assumed name, or nickname, necessary to permit check of your work or education records? If yes, please explain. Are you 18 years of age or older?* Yes No Are you either a U.S. citizen or a legal alien who has the right to remain permanently and work in the U.S.?* Yes No Have you ever been convicted of a crime?* Yes No Please describe fully the criminal conviction(s), listing the nature of the offense, you age at the time of the offense, and your rehabilitation since the conviction(s).*Note: A conviction of a crime will not be an absolute disqualification to employment. Are you related to, or is your spouse, an employee of YHS?* Yes No If “Yes”, whom?*What activities do you like to do or participate in on your time away from work?* Have you ever applied for a position with the Yavapai Humane Society?* Yes No When did you apply for a position at YHS?* Date Format: MM slash DD slash YYYY What position are you applying for?*Full time or part time desired* Full time Part Time Date you can start?* Date Format: MM slash DD slash YYYY Salary desired*Referred by Did you graduate from high school?* Yes No Please list the high school you graduated from*If “No”, do you have your GED?* Yes No Do you have a college degree?* Yes No What degree do you have and in what?*Please list the college you graduated from or the college you are currently attending (please include city and state):*Please list any further information regarding your education: Are you currently employed?* Yes No May we contact your current employer?* Yes No What professional training qualifies you for this position?*Last Employer:*Please list from and to dates, name, address and phone number of employer, salary, position and reason for leaving.Employer Two:*Please list from and to dates, name, address and phone number of employer, salary, position and reason for leaving.Employer Three:*Please list from and to dates, name, address and phone number of employer, salary, position and reason for leaving.Military ServiceIf you have served in the U.S. Armed Forces (National Guard, Army, Navy, Marine Corps, Air Force, Coast Guard), please state the conditions of your discharge, or state if you are still active or reserve, and list any special training or experience you may have received which would assist you in performing the job for which you have applied: (Please include rank) Please provide the information requested below for at least three people, not related to you, which have known you for at least one year.Reference 1:*Name, address, business, phone number and years acquaintedReference 2:*Name, address, business, phone number and years acquaintedReference 3:*Name, address, business, phone number and years acquaintedIn case of an emergency who should we contact?*(Please include name, address, and phone number) Please attach any additional information (i.e. cover letter and resume). Drop files here or By signing below: I acknowledge that I have read and understand the Yavapai Humane Society’s Equal Employment Opportunity Policy and Conditions Related to Employment with YHS on page one. The information I have provided within is complete and true to the best of my knowledge. I understand the discovery of any misrepresentation herein or omission of facts from here on will be cause not to hire me, or for my immediate termination if hired. I hereby authorize YHS to investigate my records with my former employers, personal references, motor vehicle history, and Arizona State criminal history, maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application. I release YHS and informants from any liability whatsoever resulting from such an investigation. I understand that any employment offered to me by the Yavapai Humane Society will be on a 90 day probationary basis. I agree to conform to YHS’s rules and regulations, and agree that my employment and compensation can be terminated, with or without cause, and without notice, at any time, at either my or YHS’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by YHS. Enter your digital signature belowDate* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.