I understand that the submission of all the materials listed above are required in order to complete my application for the SFMB position. *

Yes

No

Name *

First Name

Last Name

Marital Status

Single

Married

Seperated

Divorced

Widowed

Phone Number *

(###)

###

####

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Male

Female

Are you fluent in any other language besides English? *

Yes

No

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor Name

First Name

Last Name

Supervisor Phone Number

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor Name

First Name

Last Name

Supervisor Phone Number

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Supervisor Name

First Name

Last Name

Supervisor Phone Number

(###)

###

####

Reference #1 (Personal) *

First Name

Last Name

Reference #1 Phone Number *

(###)

###

####

Reference #2 (Personal) *

First Name

Last Name

Reference #2 Phone Number *

(###)

###

####

Reference #3 (Professional) *

First Name

Last Name

Reference #3 Phone Number *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Are you aware of any medical conditions that would prevent you from performing the services of a staff position without reasonable accommodation?

Option 1

Option 2

Have you been involved in any motor vehicle accidents while driving in the past 3 years?

Yes

No

Have you ever been convicted of any major or minor moving violations during the past 3 years?

Yes

No

Was the accident at-fault?

Yes

No

Do you carry at least liability insurance on your automobile?

Yes

No

I represent that each of my responses in the Staff application are truthful and accurate. I agree to notify the SFMB staff should there be any changes in the above information.

Yes

No

Sunday

Morning

Afternoon

Evening

Monday

Morning

Afternoon

Evening

Tuesday

Morning

Afternoon

Evening

Wednesday

Morning

Afternoon

Evening

Thursday

Morning

Afternoon

Evening

Friday

Morning

Afternoon

Evening

Saturday

Morning

Afternoon

Evening

I have read and agree with the STAFF RULES & REGULATIONS. *

Yes, I agree

No, I do not agree

I have read and give consent to the stipulations within the STAFF WAIVER. *

Yes, I agree

No, I do not agree

I have read, understand and agree to the statements within the STAFF AGREEMENT. *

Yes, I agree

No, I do not agree

I have read, understand and agree to the statements within the CONFIDENTIALITY & PRIVACY AGREEMENT. *

Yes, I agree

No, I do not agree

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Set Free Monterey Bay (“Employer”) at any time after receipt of this authorization and throughout my employment, if applicable. *

Yes, I agree

No, I do not agree

To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 1-888-670-9564; www.VerifiedFirst.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. *

Yes, I agree

No, I do not agree

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer.

Yes

Date of Birth *

MM

DD

YYYY

Expiration Date *

MM

DD

YYYY

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Today's Date *

MM

DD

YYYY

I agree to submit the $35 application fee through the Verified First platform online, which will cover the cost of my background check. Other forms of payment also accepted: checks made out to Set Free Monterey Bay. Or paying $35 through our website via PayPal (please put “Background Check” in the memo/note line) *

Yes, I agree

No, I do not agree

The information contained on this application is correct to the best of my knowledge. Should my application be accepted, I agree to fulfill the commitments of my job description, to be faithful to the policies of Set Free Monterey Bay, and refrain from dishonorable conduct in the performance of my services on behalf of Set Free Monterey Bay. *

I agree

I do not agree