SKOOKUM

Dear Applicant:

Thank you for taking the time to fill out our application. We want to provide the best customer service possible. Your application will be reviewed and screened by our Human Resources department.

We want to emphasize that only completed applications will be processed; you are welcome to include your resume with the application. Please fill out the entire application. Providing complete and accurate information on your education, work experience, and skills will help identify whether you are a qualified candidate for the position. Please date and sign the application. If not signed, the application is not complete and will not be processed. An incomplete application may disqualify you from being considered for the position. Additionally, you may not apply for “any position” you must specify what open position you are interested in.

If you need any further assistance completing your application please contact Skookum Human Resources at any of following locations.

Submit Applications to:

Human Resources4525 Auto Center Way~PO Box 5359Bremerton, WA 98312cday@skookum.org[->0](360) 475-0756 1-888-343-0220 (360) 475-0757 (fax)|

Again, thank you for your interest in Skookum. Good Luck!

Skookum

SKOOKUM Job Application

Your Name: ___Cocheta Sanders__________________________________________Date:___________________

Welcome to Skookum: America’s Premier Non-Profit Contract Management Corporation. We would like to thank you for your interest in one of our current job openings. Please let us know if you need assistance with any part of this application, as this information is important for helping us learn about you.

NISH Eligibility Determination
Most of Skookum’s direct labor positions are supported by NISH which is an agency who helps those with disabilities as barriers to employment in obtaining jobs. Our mission at Skookum is “Creating Opportunities for People with Disabilities”. Your chances of being hired with us increase if you do have a disability. If you accept a NISH supported position at Skookum, we will require medical documentation of your disability and have provided a sample letter of what is acceptable for our records on the last page of this application. You may take the sample letter with you and give it to your doctor.

In order to determine if you qualify with a disability for employment under our NISH contracts, we have provided a list below of reasons how you may qualify. Thoroughly review the list and then mark the box below.

1.
1. Treatment for depression or other mental health issues.
2. Department of Rehabilitation (DVR) referral.
3. Recent substance abuse counseling or treatment program.
4. Severe Veteran’s disability

5. Previous developmental assistance
6. Medical treatment for a chronic (long-term) condition
7. Any other medically documented disability

Please mark which box applies to you below:
□ Yes, I do feel I qualify with a disability barrier based on the above list so please place my application on the priority/preferred processing list. I will provide documentation if a job is offered.
□ No, I do not feel I qualify with a disability barrier based on the above list, but please accept my application anyway. Please consider my qualifications for positions that are not NISH contracted.
X N/A, I am applying for an executive, professional, administrative or overhead support position and therefore it will not be necessary to qualify with a barrier through NISH.

Criminal Background Checks

If the position you are applying for requires you to work on Military Installations there may be additional background checks conducted and security clearance might not be obtainable with any previous felony charges on your record.

Washington State statue and regulation require licensed, certified, registered person(s), and those working in facilities that have unsupervised access to vulnerable adults, to complete a background check. The background check is confidential information and is used only for the purpose of determining whether the applicant should be licensed, hired, or engaged in positions with unsupervised access to vulnerable adults.

To work for Skookum you cannot have any of the DSHS Crimes and Negative actions showing on your record. Please refer to the DSHS website for a list of crimes: http://dshs.wa.gov/word/bccu/Secretary's%20Crimes%20List%20for%20All%20Programs%20except%20ADSA%20RCS,%20HCS%2012-1-2011.docx If you have been convicted of any of these crimes you need not continue with the application process. Please refer to Washington State RCW 43.43.830 and RCW 43.43.842 for further information on these statues and regulations. If you have been convicted of any of these crimes Skookum will not be able to hire you due to liability issues with the vulnerable adults we employ.

If hired and your background check comes back with any DHSH Crimes and Negative actions on your record, we will be forced to terminate you immediately. So we ask that you please be honest at the beginning of the application process.

Application Form
Please fill out our application form and reference section completely.

We would like the application process be as easy for you as possible. Please let us know right away if you need help in completing these forms or if you need any special accommodations.

You are welcome to attach your resume to the application, however our application is required!

All forms may be faxed, emailed or returned to the Human Resources Office at:
Human Resources4525 Auto Center Way~PO Box 5359Bremerton, WA 98312cday@skookum.org[->1](360) 475-07561-888-343-0220 (360) 475-0757 (fax)|
Again, thank you for your interest in Skookum. Please provide as much information as possible so we can get the best picture of who you are when we review your application. Good Luck!

Creating Opportunities for People with Disabilities

Skookum| Employment Application|
GENERAL|
Name (Last) (First) (Middle) Sanders Cocheta Taushelia|Today’s Date (Month, Day, Year)|
Address (Number & Street) (City) (State) (Zip) 9119 Cloisters east Richmond VA 23229|Home Telephone ( 804 ) 467-0952|
Email AddressCocheta_s@yahoo.com[->2]| Cell Phone ( 804 ) 339-2407|
Are you younger than 18 years of ageo Yes x No |Are you a United States citizen? x No o Yes If not a United States citizen, do you have documentation to work in the United States? o No o Yes |
POSITION|
Job Title for which you are applying. You may not apply for “any position” you must specify what open position you are interested in. | Job #|Have you previously interviewed for any positions at Skookum? x No o Yes Previously employed by Skookum? x No o Yes| Salary Desired:|Date Available:| WORK AVAILABILITY (CHECK ALL THAT APPLY)|
Check all type (s) of Employment you will accept: x Full Time o Part Time o On Call o Temporary |Check all shifts you are willing to work: x Days o Swing o Graveyard o Rotating x Weekends x Holidays| | | | | | | | | | |
ADDITIONAL INFORMATION|
Have you lived in Washington State for the past 7 years? x No o Yes If no, what States other than Washington have you lived?: Do you have relatives that work for Skookum? x No o Yes If Yes, list them: |
Have you ever been convicted of a gross misdemeanor or felony? x No o Yes If Yes, tell which, give dates and explain the circumstances fully: Answering Yes does not necessarily disqualify you; however, a background check will be conducted prior to employment to verify any disqualifying crimes as cited on page 3 of this application.|
With or without accommodations, can you perform the essential job functions of the position(s) for which you are applying? x No o Yes (A copy of the job description stating essential functions is available for your review). |
Personal Reference__Chantelle Green_______________________________________________|Home Phone_804-284-6098__________________________________| ||||||||| |
Address______________________________________________________________________How do they know you?|Business Phone_________________________________|
EMPLOYMENT EXPERIENCE(Start with your present or most recent job).|
Employer|Dates Employed (Month/Year)From: To: |Hourly Rate/Salary (Starting - Final)$ |
Job Title|Supervisor Name |o Full-Time o Paid o Part-Time o Volunteer|
Address |Phone Number(s)|Reason for Leaving:|
|May we contact this employer? o No o Yes ||
Duties Performed:|
Employer|Dates Employed (Month/Year)From: To: |Hourly Rate/Salary (Starting - Final)$ |
Job Title|Supervisor Name |o Full-Time o Paid o Part-Time o Volunteer|
Address |Phone Number(s)|Reason for Leaving:|
|May we contact this employer? o No o Yes || Duties Performed: |
Employer|Dates Employed (Month/Year)From: To: |Hourly Rate/Salary (Starting - Final)$ |
Job Title|Supervisor Name |o Full-Time o Paid o Part-Time o Volunteer|
Address |Phone Number(s)|Reason for Leaving:|
|May we contact this employer? o No o Yes ||
Duties Performed:|
Employer|Dates Employed (Month/Year)From: To: |Hourly Rate/Salary (Starting - Final)$ |
Job Title|Supervisor Name |o Full-Time o Paid o Part-Time o Volunteer|
Address |Phone Number(s)|Reason for Leaving:|
|May we contact this employer? o No o Yes|| Duties Performed:|
|| Skookum||
|| Creating Opportunities For People With Disabilities.|
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REFERENCE REQUEST|
Applicant, In the fields with an asterisk, write in information and sign. *Applicant Name:_______________________________________________________|
*Previous Employer: __________________________________________________________________ *Attn:___________________________________________*Address:____________________________________________________________________________ *Phone:_________________________________________ |
I have recently applied for employment with Skookum and I hereby give permission to them to verify my past employment history with your company.|
*Applicant Signature:____________________________________________________________________ *Date:________________________________________ | | | | | | | | | | |
|| Skookum ||
|| Creating Opportunities For People With Disabilities.|
|||||| |
REFERENCE REQUEST|
Applicant, In the fields with an asterisk, write in information and sign: *Applicant Name:__________________________________________________________|
*Previous Employer: __________________________________________________________________ *Contact Name:__________________________________*Address:____________________________________________________________________________ *Phone:_________________________________________ |
I have recently applied for employment with Skookum and I hereby give permission to them to verify my past employment history with your company.|
*Applicant Signature:____________________________________________________________________ *Date:________________________________________ |
EDUCATION/TRAINING|
| ||Vocational |Undergraduate|| | | High School|Training/School|College/University| | Graduate| School Name/Location| | | | | | | | | Diploma/Degree Year of Graduation| oGraduated oGEDYear not applicable for High School| | | | | | | Number of Years Completed| | | | | | | | | Course of Study| | | | | | | | |
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LICENSES/CERTIFICATES|
License/Certificate Type|State|License/Certificate Number|Effective Date|Expiration Date|
||| | | | | | | | Driver’s License: o No o Yes | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
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INFORMATION CERTIFICATION / AUTHORIZATION TO RELEASE INFORMATION|
I certify the information given in this Application for Employment is true and complete to the best of my knowledge. I authorize Skookum to verify my educational credentials and professional licenses and to make inquiry of my former employer or references as to my experience, job suitability, and/or reasons for leaving. I understand that if employed, the making of false statements on this Application, or omission of information, will be sufficient cause for my termination. Offers of employment are contingent upon satisfactory references from former employers and colleagues. I agree to hold harmless Skookum and any company and/or individual (s) for information they may release with regard to this Application|
I understand that any job offer made is contingent upon proof of identity and verification of eligibility for employment in the United States. I also understand that any job offer made is contingent upon a satisfactory criminal history background check. I also understand any job offer made is contingent upon passing a drug and alcohol screening, submission of required disability documentation, being bondable by Skookum’s insurance to drive for Skookum, and/or passing security clearance processing, if any of these conditions are required for the position I am applying for.|
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I also understand that if hired, I may voluntarily resign or be terminated by Skookum at any time with or without reason. If I accept a position with Skookum, I agree to comply with all its policies and procedures. In the event of termination of employment with this company, I agree to return all its property such as parking permit, keys, ID badges, uniforms and etc. I authorize Skookum to withhold all or part of the wages due to me and to apply those wages against any debt I owe to the company.| |||||||||| ||||||||||
Signature of Applicant:__________________________________________________________________Date:____________________________ |
SKOOKUM IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER|
Skookum is committed to enhancing the diversity of our staff and administration, as well as our community. We strongly encourage all applicants to apply without regard to race or ethnicity, creed, color, sex, national origin, age, marital status, religious preference, life-threatening illness, the presence of any (non-job-related) sensory, mental, or physical disability, reliance on public assistance, sexual orientation, status as a disabled or Vietnam-era veteran, or political opinions or affiliations, or any other legally protected status. Applicants who require assistance with the recruitment process will be accommodate to the extent reasonably possible. Skookum maintains a drug-free environment.|

Criminal Background Check

Statutes and regulations require licensed, certified, registered person(s), and those working in facilities that have unsupervised access to vulnerable adults, to complete a background check. The background check is confidential information and is used only for the purpose of determining whether the applicant should be licensed, hired, or engaged in positions with unsupervised access to vulnerable adults.

The following information will be used to conduct a criminal background check:

Please read the following statement carefully:
I understand Skookum may conduct, and I hereby consent to, a thorough background investigation, including examination of records maintained by law enforcement agencies and examination of my driving record. I release Skookum, its employees, officers, members, and board members and its affiliates (hereby altogether known as Skookum) and all other persons and entities without limitation from any claim arising out of or related to any background investigations, reference checks, or disclosures including the evaluation of my fitness for employment.

_________________________________ _________________________________ Applicant Signature Date

AFFIRMATIVE ACTION QUESTIONNAIRE
(CONFIDENTIAL-FOR STATISTICAL USE ONLY)
We are an Equal Employment Opportunity (EEO) Employer and do not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation or any other classification protected by Federal, state, or local law. The information below will be used only in the compilation of data for Affirmative Action reporting; therefore this form will be removed from the application and stored separately.
Completion of this data is voluntary and will not affect your opportunity for employment, or terms or conditions of employment, if hired. To comply with government regulations, the minimum amount of information required on this report is your printed name, signature and date. The rest of the information below is voluntary, but will be very helpful to us to ensure we are doing our best in our EEO recruitment efforts. Please return this page with your application for processing.

Business Name: Skookum Applicant's City/State: _______________________________
Position Applied For: _______________________________________________________________
Where you heard about the position:___________________________________________________
Applicant Name: (Print) ___________________________________________________________________
Gender: □ Male □ Female Disabled (ADA): □Yes □No Date of Birth: ____/_____/_____
Disabled Veteran: □Yes □No Veteran: □Yes □No Vietnam Veteran: □Yes □No
Gulf Veteran (1990-2001): □Yes □No Combat Disabled Gulf Veteran (1990-2001): □Yes □No
Iraq Veteran (Post 9/11): □Yes □No Combat Disabled Iraq (Post 9/11) Veteran: □Yes □No
Afghanistan Veteran: □Yes □No Combat Disabled Afghanistan Veteran: □Yes □No
Branch of Service: □Army □Navy □Air Force □Marines □Coast Guard □National Guard
ETHNIC GROUP: (Please check one of the descriptions below for the ethnic group with which you most identify.)
□ American Indian or Alaskan Native - A person having origins in any of the original peoples of North
America and South America (including Central America), and who maintains tribal affiliation or community attachment
□ 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
□ 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, Samoa, or other Pacific Islands
□ White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
□ Hispanic or Latino - A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
□ Information is missing or unknown - Applies to Applicants where a resume or application that is screened is received without any racial or ethnic identification and no further contact is made with the applicant.

Applicant Signature: ____________________________________________Date: _______________

AUTHORIZATION FOR DRIVING RECORD

I, the undersigned, do hereby authorize Skookum to obtain from the State in which I hold my driver’s license, an abstract of my driving record for use in claims investigation, rating and underwriting the insurance for which Skookum has applied, and renewal thereof. I understand that in obtaining a Driving Record, a Consumer Reporting Agency may be used by Skookum or their authorized insurance representative and do hereby authorize such use.

Print Name:|
Date of Birth:|
Driver License Number:|
State: |
Expiration Date:|
Signature:|
Date:|
For office use only:Dept# __________Location ______________________________HR Representative Initials ___________Bremerton Fax: (360) 475-0759|

Sample Letter For Health Care Provider

(Must be on Health Care Provider’s Letterhead)

Today’s date

Dear Skookum:

This letter is to inform you that patient’s name is a patient’s age year old male/female who has been diagnosed with Axis I and/or Axis III code since date of diagnosis. This diagnosis was determined by medical tests/evaluations ex: WISC-R, Bender-Gestalt, etc.

This condition is chronic, degenerative, etc. This disability substantially limits patient’s name because explanation.

Future treatment includes medications, physical therapy, counseling, etc.

The following restrictions may apply - ex: no lifting over 40lbs,

The following reasonable accommodations may apply - ex: may need more frequent breaks

Patient’s name will continue to need assistance through job support supplied by your organization. This support may range from reasonable accommodations to counseling and vocational rehabilitation. Patient’s name is an excellent candidate for your program.

Sincerely,

Health care provider’s signature

(must be signed by an MD, PhD, or DC)

[->0] - mailto:cday@skookum.org
[->1] - mailto:cday@skookum.org
[->2] - mailto:Cocheta_s@yahoo.com