Human Resources Department

714 South 27th Street

Tacoma, WA 98409-8193
(253) 272-5166
(253) 428-4162 Fax
www.tacomagoodwill.org
Personal Information
Position Applied For Date

Name

Address

City State ZIP Code

Telephone: Daytime Evening Message

E-mail Address

Availability and Employment Information

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 Goodwill?  Yes  No If yes, when and where?

Are you 18 years or older?  Yes  No

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

Education and Training

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

High School Yes No

Business or
Yes No
Trade School
College or
Yes No
University
Graduate
Yes No
School

List any additional training and special skills

List registrations, certifications, and licenses

Rev. 9/05
Employment Record List most recent employment first. All fields must be completed.

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:

Rev. 9/05
Referral Source Please check all that apply:

 Job Posting at Goodwill Place of Business

 Newspaper/Publication:
 Tacomagoodwill.org
 Monster.com
 Other Website:
 Work Source or Job Service
 Goodwill Employee:
 Job Fair
 Word of Mouth
 Other:

Application Certification Please read carefully before signing.

Employment with Tacoma Goodwill Industries is at-will and may be terminated at any time for any reason
with or without cause, with or without notice, by the employer or employee. I understand that no
management official is authorized to make any verbal assurance or promise of continued employment.

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 accompanying 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 employee.

I understand that employment with Tacoma Goodwill Industries may rely upon information 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 with 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, educational institutions,
and references to obtain and verify the accuracy of information contained on my application materials. I
also hereby release from liability Tacoma Goodwill Industries and its representatives for seeking, gathering,
and using such information to make employment decisions and I also hereby release from liability 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

Rev. 9/05
 BACKGROUND INQUIRY AUTHORIZATION
Tacoma Goodwill Industries is directly responsible for the supervision of persons 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 made to state and/or federal
law enforcement agencies. Information obtained from this disclosure statement or background inquiries 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 any 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; murder; manslaughter; kidnapping; first degree
arson; first, second or third degree extortion; first or second degree child molestation; incest; first degree promoting prostitution;
communication with a minor; sexual exploitation of a minor; first or second degree criminal mistreatment; unlawful imprisonment;
indecent liberties; child abuse or neglect; first or second degree custodial interference; first or second degree custodial 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 abuse
restraining order; child buying or selling; criminal abandonment; crimes related to drugs (manufacture, delivery or possession with intent
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)

Social Security Number Birth Date

Sex Race Height Weight Hair Color Eye Color

Have you lived in the state of Washington for at least 3 years?  Yes  No
If no, 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 board 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 vulnerable 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 Disclosure Statement is true,
complete and correct. I understand that any omission or misstatement of fact may be cause for termination of
employment.

Signature Date
Rev. 9/05