Author: Theresa Chaplin

Date .

Pioneer Camp & Retreat Center
9324 Lakeshore Road
Angola, NY 14006
716-549-1420

Name .
Address City State Zip .
Home Phone Cell Phone .
Email .
Position Desired .
Wage Desired .
Date Available to Start .

Education	Name of School	Course of Study	Degree Held

List certifications of special training which would be applicable for this position (please list expiration dates, if applicable) .
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Do you have a valid New York State driver’s license? . Yes . No
Have you been convicted of a crime? . Yes . No
If yes, please explain ,
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May we contact your previous employer? . Yes . No
If no, indicate which one you do not wish us to contact .
Please continue on the back

Do you have any physical, mental or medical conditions that would interfere with your ability to do the job that you are applying for, or with your ability to come to work regularly? . Yes . No
If yes, please explain ,
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Work history: List ALL previous employers, starting with your most recent employment first. If you are presently employed, list present employment first and reason for wanting to leave. Please give any reasons for termination or quitting. If you need more room attach a separate sheet of paper.

Name of Company & Supervisor	Position/Title	Wage Earned	Start & End Date	Reason left/terminated

References: Please list names, addresses and phone number of three persons (no relatives) who have knowledge of your character, experience and ability. This section is required for employment.

Name	Position/Title	Address, City, State & Zip	Phone Number

Do you give Pioneer permission to do a complete background check? . Yes . No

I give permission to contact any previous employer and/or reference . Yes . No

Applicant: Your signature below verifies that you have completed this application and that all information is true to the best of your knowledge. If employed, any false statements on this form are grounds for immediate dismissal.

Applicants signature . Date .