APPLICATION FOR EMPLOYMENT

Tacoma Goodwill
GOODWILL BJCL Pantone541

Doing business in Tacoma, Lacey, Olympia, Centralia, Longview,

Yakima, Selah, Ellensburg, Port Townsend, and Port Angeles
---

Date:

Position Applied For

Location:
---

Name

Address

City State ZIP Code

Telephone: Home Cell Other

E-mail Address
---

When are you available for work? (Check all that apply):

. Monday-Friday . Saturday . Sunday . Daytime . Evening

List any friends or relatives you have working here

Have you ever worked for Tacoma Goodwill? . Yes . No If yes, when?

Can you verify your legal rights to work in the U.S. by providing a birth certif
icate/proof of U.S.
citizenship, or employment authorization? . Yes . No

---

Human Resources Department

714 South 27th Street
Tacoma, WA 98409-8193

At Goodwill, we welcome people with diverse backgrounds, including persons with

disabilities
or other disadvantages. In fact a substantial portion of our employees have a di
sability and/or
economic disadvantage and we strongly encourage such persons to apply.
Employment Record
Starting with you most recent employment, list your employment history. You may
add additional pages in
order to list your complete employment history. All information requested should
be complete to the extent
possible.

1) Name of Company City, State

Position Held Supervisor

Date Began Date Ended Telephone

Beg. Wage End Wage May we contact? . Yes . No

Duties

Reason for Leaving

2) Name of Company City, State

Position Held Supervisor

Date Began Date Ended Telephone

Beg. Wage End Wage May we contact? . Yes . No

Duties

Reason for Leaving

3) Name of Company City, State

 Position Held Supervisor

Date Began Date Ended Telephone

Beg. Wage End Wage May we contact? . Yes . No

Duties

Reason for Leaving

4) Name of Company City, State

Position Held Supervisor

Date Began Date Ended Telephone

Beg. Wage End Wage May we contact? . Yes . No

Duties

Reason for Leaving

Explain any time between jobs:

Education and Training

Education
Level
School Name
City, State
Course of Study
Graduate?
Circle one
High School

Yes No
Business or
Trade School

Yes No
College or
University

Yes No
Graduate
School
Yes No

List any additional training and special skills

Application Certification Please read carefully before signing.

Employment with Tacoma Goodwill Industries is at-will and may be terminated at a

ny time for any reason with
or without cause, with or without notice, by the employer or employee. I underst
and that no management
official is authorized to make any verbal assurance or promise of continued empl
oyment.

I certify that the information given by me to Tacoma Goodwill Industries is true

and correct, and that
falsification, misrepresentation, or omission on this application (or accompanyi
ng documents) may
result in separation of employment.

I agree to provide identification and employability documents if I am hired.

NOTE: Tacoma Goodwill conducts a Criminal Background Check on EVERY potential em

ployee.

I understand that employment with Tacoma Goodwill Industries may rely upon infor
mation received relating to my
CRIMINAL BACKGROUND HISTORY and PRE-EMPLOYMENT DRUG SCREEN. I freely consent to
a pre-
employment drug screen as required by Tacoma Goodwill Industries in compliance w
ith Goodwill's Drug-Free
Workplace Policy. Failure to consent to, or an unsatisfactory result from, a pre
-employment drug screen will
immediately discontinue my consideration for employment.

I hereby authorize Tacoma Goodwill Industries to contact my former employers, ed

ucational institutions, and
references to obtain and verify the accuracy of information contained on my appl
ication materials. I also hereby
release from liability Tacoma Goodwill Industries and its representatives for se
eking, gathering, and using such
information to make employment decisions and I also hereby release from liabilit
y all other persons or
organizations for providing such information.

I represent and warrant that I have read and fully understand the foregoing, and
that I seek employment at
Tacoma Goodwill Industries under these conditions.

Signature

Print Name Date

BACKGROUND INQUIRY AUTHORIZATION

Tacoma Goodwill Industries is directly responsible for the supervision of person

s with developmental disabilities. RCW 43.43
requires employment applicants to sign a disclosure statement, under penalty of
perjury, relating to certain conviction records,
civil adjudications, and disciplinary board final decisions. Inquiries may be ma
de to state and/or federal law enforcement
agencies. Information obtained from this disclosure statement or background inqu
iries will not necessarily disqualify you for
employment, but will be considered in making that decision. Failure to complete
and sign this form will disqualify you from
further consideration for employment.

For the purposes of this disclosure statement, "crimes against persons" means an
y of the following offenses:
Simple assault, domestic violence, first, second, third or fourth degree assault
or rape; forgery; first or second degree robbery or burglary;
first, second or third degree theft; aggravated murder or vehicular homicide; mu
rder; manslaughter; kidnapping; first degree arson; first,
second or third degree extortion; first or second degree child molestation; ince
st; first degree promoting prostitution; communication with a
minor; sexual exploitation of a minor; first or second degree criminal mistreatm
ent; unlawful imprisonment; indecent liberties; child abuse or
neglect; first or second degree custodial interference; first or second degree c
ustodial sexual misconduct; malicious harassment; first or
second degree sexual misconduct with a minor; patronizing a juvenile prostitute;
child abandonment; promoting pornography; selling or
distributing erotic material to a minor; custodial assault; violation of child a
buse restraining order; child buying or selling; criminal
abandonment; crimes related to drugs (manufacture, delivery or possession with i
ntent to manufacture or deliver a controlled substance); or
any of these crimes as they may be renamed in the future.

Personal Information

Full Name

Maiden Name or Alias(es)

Birth Date

Sex Race Height Weight Hair Color Eye Color

Have you ever lived anywhere beside Washington State? . Yes . No

If yes list other states you have lived in:

Background History

1) Have you ever been convicted of a crime against persons?

2) Have you ever been found in any dependency action under RCW 13.34.030 (2) (b)
or by

a court in a domestic relations proceeding under Title 23 RCW or disciplinary bo

ard final
decision to have sexually assaulted, exploited, or physically abused any minor?

3) Have you ever been convicted of crimes relating to the financial exploitation
of a vulnerable adult

or been found in any disciplinary board decision or court protective proceeding

to have sexually or
physically abused or exploited any developmentally disabled person or vulnerabl
e adult?
4) If you answered yes to any question, explain, giving date and location:

I hereby authorize Tacoma Goodwill Industries to request information relating to

my criminal background. I understand that
such inquiry may be to federal and/or state law enforcement agencies and that a
copy of each response will be made
available to me upon my request.

I attest under penalty of perjury that the information I have provided on the Di
sclosure Statement is true, complete
and correct. I understand that any omission or misstatement of fact may be cause
for termination of employment.
Signature Date
FREE SERVICES REQUEST

Are you interested in learning more about Goodwill s free programs and services?
We can help you update your skills; polish your resume; practice interviewing an
d more.

Please check all services that are of interest to you.

Our Workforce Customer Service Representative will contact you shortly to discus
s your options.

Areas of interest (please check all that apply):

. Information about the next Orientation Session about all services & programs a
t Goodwill
. Access to current job leads (eligibility requirements apply)
. Paid and unpaid work experience
. Free Computer Classes
. Job Clubs - beginners or advanced
. Job Readiness Classes (interview practice, resume writing, etc)

By signing this Service Request, you are giving us permission to contact you. Th
is request
will be separated from your employment application with Tacoma Goodwill.

Name_________________________________________________________________________

Phone
Number(s)_______________________________________Email__________________________

Signature
______________________________________________Date____________________________

Thank you for your interest in Tacoma Goodwill Industries.