APPLICATION FOR EMPLOYMENTPERSONAL INFORMATIONLast Name     

First     

Initial     

Other Name(s) Used     

Home Telephone #(     )      

Address (Street, City, State, Zip)     

Business or Message #(     )      

Position Applied For:     

How were you referred to us?     

Salary Desired:     

Have you ever interviewed with Catalyst or its affiliates before?

Yes No

If yes, list date(s), job title(s) & location(s)     

Have you ever been employed by Catalyst or its affiliates? Yes No

If yes, list date(s), job title(s) & location(s)     

Do you have any relatives currently employed by Catalyst or its affiliates?

Yes No

If yes, list date(s), job title(s) & location(s)     

Are you 18 years of age or older? Yes No Date Available to Start Work:      

Type of Employment Desired: FT PT Temporary Other:      

Will Visa or immigration status prevent lawful employment in the U.S.? Yes No

Are you able to travel if this position requires it? Yes No

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the essential activities involved in the job or occupation for which you have applied? Yes NoHave been convicted or pled no contest to any criminal offense? (A conviction will not necessarily disqualify an applicant from employment.) Yes NoIf yes, please indicate the date and nature of the offense:

FOR WAREHOUSE/INSTALLATION POSITIONS ONLY:Washington Driver’s License #:     

Have you had any traffic violations in the past 5 years?

Yes NoIf yes, please explain:     

An Equal Opportunity EmployerCatalyst Workplace Activation is an equal opportunity employer. Applicants are considered for employment without regard to race, color, religion, sex, national origin, age, genetic information, otherwise qualified disabled or veteran status, or any other basis prohibited by local, state, or federal law.

7/1/2016

EDUCATION

Check Highest Grade Completed: High School 9 10 11 12College, Trade or Business 1 2 3 4Graduate Studies      

School Name Location (City & State) Number of Years

Attended

Major Degree, Diploma,License or Certificate

Received

High School                        

College/University                        

Vocational, Business, Other

                       

List Any Professional Designations     

Other Special Knowledge, Skills or Qualifications     

SKILLS Please place an “X “ next to skills you currently have

Microsoft Word 2     : Microsoft Outlook 2     :Microsoft Excel 2     : Web/Internet Tools: e.g.:      Microsoft Publisher 2     : AutoCAD:MS Access 2     : Microsoft PowerPoint 2     :Other Software/Skills:      

REFERENCES Please include only those who know your work habits. Do not include relatives.

Name     

Phone #(     )      

Relationship     

Years Known     

Name     

Phone #(     )      

Relationship     

Years Known     

Name     

Phone #(     )      

Relationship     

Years Known     

EMPLOYMENT EXPERIENCE

An Equal Opportunity EmployerCatalyst Workplace Activation is an equal opportunity employer. Applicants are considered for employment without regard to race, color, religion, sex, national origin, age, genetic information, otherwise qualified disabled or veteran status, or any other basis prohibited by local, state, or federal law.

7/1/2016

List all employment for the past 10 years, starting with the most recent position. All information must be completed. You may attach a resume, but not in place of completing the required information. If you need additional space, please continue on a separate piece of paper.

If currently employed, may we contact your employer? Yes NoEmployer      Dates Employed Work PerformedAddress     

From     

To           

Telephone Number(s)      Hourly Rate/Salary Reason for LeavingJob Title     

Supervisor     

Starting     

Ending           

Employer      Dates Employed Work PerformedAddress     

From     

To           

Telephone Number(s)      Hourly Rate/Salary Reason for LeavingJob Title     

Supervisor     

Starting     

Ending           

Employer      Dates Employed Work PerformedAddress     

From     

To           

Telephone Number(s)      Hourly Rate/Salary Reason for LeavingJob Title     

Supervisor     

Starting     

Ending           

Employer      Dates Employed Work PerformedAddress     

From     

To           

Telephone Number(s)      Hourly Rate/Salary Reason for LeavingJob Title     

Supervisor     

Starting     

Ending           

LIST PROFESSIONAL, TRADE, BUSINESS OR CIVIC ACTIVITIES AND OFFICES HELD.You may exclude membership that would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.                    

APPLICANT’S STATEMENT - PLEASE READ CAREFULLY BEFORE SIGNING

An Equal Opportunity EmployerCatalyst Workplace Activation is an equal opportunity employer. Applicants are considered for employment without regard to race, color, religion, sex, national origin, age, genetic information, otherwise qualified disabled or veteran status, or any other basis prohibited by local, state, or federal law.

7/1/2016

I certify that the information given by me to Catalyst Workplace Activation (Catalyst) is true and complete to the best of my knowledge. I understand that if I am employed, discovery that I gave false information during the application process may result in immediate dismissal.

I further certify that I am not engaged in any outside activity or business that could be considered in conflict with Catalyst’s interest or those of its customers, nor will I become engaged in such activity or business if employed.

I authorize Catalyst Workplace Activation to solicit information regarding my character, general reputation, credit, previous employment and education, criminal and civil history, and/or similar background information, and to contact any and all references I have given on my application. I hereby release all parties and persons connected with any such request for information from all claims, liabilities and damages for any reason arising out of the furnishing of such information. If employed, I release the company from any liability for future references it may provide regarding my work history with Catalyst Workplace Activation.

In consideration of employment, I agree that my employment and compensation can be terminated with or without reason, and with or without notice at any time, at the option of either Catalyst or myself. I understand that no representative of Catalyst Workplace Activation, other than the President, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

I understand that it is Catalyst’s policy not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I understand that if I am extended an offer of employment it is contingent upon my successfully passing a pre-employment drug screen. I understand that a confirmation of a positive result on a drug screening will result in my not be considered for employment.

I represent and warrant that I have read and fully understand the forgoing, and that I seek employment under these conditions.

Applicant signature: ___________________________________________ Date: ________________________

Application Will Remain Active For 30 Days

An Equal Opportunity EmployerCatalyst Workplace Activation is an equal opportunity employer. Applicants are considered for employment without regard to race, color, religion, sex, national origin, age, genetic information, otherwise qualified disabled or veteran status, or any other basis prohibited by local, state, or federal law.

7/1/2016

APPLICANT AFFIRMATIVE ACTION INFORMATIONCatalyst Workplace Activation is subject to certain governmental record-keeping and reporting requirements for the administration of civil rights laws and regulations. To comply with these laws, the employer invites applicants to voluntarily self-identify gender, race, and ethnicity. Submission of this information is voluntary, and refusal to provide it will not subject you to any adverse treatment. The information is kept confidential and is only used in accordance with the provisions of applicable laws, executive orders and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

It is the policy of this organization to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, sex, age, veteran status, disability, genetic information, or other basis protected by local, state, or federal law.

Please Print

Name:       Date:      

Position Applied for (list only one):      

1. Are you Hispanic or Latino/a? A person of Cuban, Mexican, Chicano/a, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Yes (Skip to question #3)

No (Go to question #2)

3. What is your gender?

Male

Female

2. What race or races do you consider yourself to be? (Check all that apply)

White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Black or African American: a person having origins in any of the black racial groups of Africa

Native Hawaiian or other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific Islands

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

American Indian or Alaskan Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment

I do not wish to Self-Identify