Employment Application Form Home / Employment Application Form Employment Application Form Step 1 of 8 12% Personal InformationName* First Middle Last Preferred Name* Cell Phone*Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Email Address* EducationHigh School* Graduation Date MM slash DD slash YYYY College/University (if applicable) Major Position Applying for:What position are you applying for?*Select PositionFront Desk AttendantHousekeeperKitchen Help-F and PTMaintenance WorkerGroundskeeperGuest ServicesOtherAre you a past Taconic Retreat Center staff member? Yes No If yes, which year(s) and what position(s) have you served on the Taconic staff?How did you find out about job opportunities at Mirror Lake Retreat?* Certifications:CPR CPR CPR Expires ServSafe ServSafe ServSafe Expires Basic First Aid Basic First Aid Basic First Aid Expires Lifeguard Lifeguard Lifeguard Expires Water Safety Instruction Water Safety Instruction Water Safety Instruction Expires Wilderness CPR Wilderness CPR Wilderness CPR Expires Legal Violations:Have you ever been convicted of a crime? Yes No If yes, please explain: Employment History Please List up to three past employers, assignments or volunteer activities, starting with the most recent. Employer #1Company Name:* Phone*Supervisor* Dates of Employment* Work Performed*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer #2Company Name: PhoneSupervisor Dates of Employment Work PerformedAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer #3Company Name: PhoneSupervisor Dates of Employment Work PerformedAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If previously employed by another summer camp, please provide the following information: Camps & LocationsPosition(s): Date(s): Please provide two personal references:Reference #1Name* Cell Phone*How do you know him/her?* Email* Reference #2Name* Cell Phone*How do you know him/her?* Email* Verification: I hereby authorize Mirror Lake Retreat to contact all prior employers and any references provided here in the hiring process to verify all information related to my character and past work performance. I further hereby release all references and prior employers from any liability for information provided in good faith. I hereby affirm and acknowledge, by signing below that all of the information in this employment application is true and complete. If I move forward in the hiring process, I agree to sign a release form to have a background check run on my background. I further understand that if I am offered a position at Mirror Lake Retreat, I will carefully read the Mirror Lake Retreat Staff Policy Manual and agree to follow these policies fully during my time on staff at MLR. I understand that if hired I will be committing myself to a position of service and that my actions should reflect my willingness to serve. Applicant's Signature*Date* MM slash DD slash YYYY Enter your Name* Parent/Guardian Signature (if under 18):Date MM slash DD slash YYYY Mirror Lake Retreat does not discriminate on the basis of race, age, sex, creed, national origin, or disability.
