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 Resources
4525 Auto Center Way/PO Box 5359
Bremerton, WA 98312
cday@skookum.org
(360) 475-0756 phone
(888) 343-0220 toll free
(360) 475-0759 fax
Again, thank you for your interest in Skookum. Good Luck!
Skookum
Skookum Employment Application
Page 1 of 11
HR AP 1.10
June 11, 2013
SKOOKUM
Employment Application
Your Name: _____________________________________________
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. Treatment for depression or other
mental health issues.
2. Department of Rehabilitation
(DVR/DARS/DORS) referral.
3. Recent substance abuse counseling or
treatment program.
4. Severe Veteran’s disability
5. Previous developmental assistance
6. Medical treatment for a chronic (longterm) 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.
□ Yes, I am a disabled veteran.
□ 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.
□ 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.
Skookum Employment Application
Page 2 of 11
HR AP 1.10
June 11, 2013
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%20A
LTSA%20RCS,%20HCS%2003-18-2013.doc
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 DSHS 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 Resources
4525 Auto Center Way~PO Box 5359
Bremerton, WA 98312
cday@skookum.org
(360) 475-0756 phone
(888) 343-0220 toll free
(360) 475-0759 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!
Skookum Employment Application
Page 3 of 11
HR AP 1.10
June 11, 2013
Employment Application
Applicant Information
Name
(Last)
Address
(First)
(Number & Street)
Today’s Date (Month, Day, Year)
(Middle)
(City)
(State)
(Zip)
Home Telephone
(
Email Address
Cell Phone
(
Are you younger than 18 years of age
□ No
)
)
Are you a United States citizen?
□ No □ Yes
If not a United States citizen, do you have documentation to work in the United States?
□ No □ Yes
□ Yes
Position Information
Job Title for which you are applying. You may not
apply for “any position” you must specify what open
position you are interested in.
Have you previously interviewed for any positions at
Skookum?
Job #
□ No
□ Yes
Salary Desired:
Previously employed by Skookum?
□ No □ Yes
Date Available:
Check all types of Employment you will accept:
Check all shifts you are willing to work:
□ Full Time
□ Part Time
□ On Call
□ Days
□ Temporary
□ Swing
□ Rotating
□ Graveyard
□ Weekends
□ Holidays
Additional Information
Have you lived in your current state for the past 7 years?
Do you have relatives that work for Skookum?
Have you ever held a DoD Clearance?
□ No
□ No
□ Yes
□ No
□ Yes
□ Yes
If no, in what other states have you lived?
If Yes, list them:
If yes, list level of clearance and dates held:
Have you ever been convicted of a gross misdemeanor or felony?
□ No
□ 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?
□ No
□ Yes
(A copy of the job description stating essential functions is available for your review).
How did you hear about this position?
□ DVR/DARS/DORS
□ Craigslist
□ Indeed
□ Veterans Administration
□ Kitsap Mental Health
□ Current Contractor
□ Job Fair
□ CRP
□ State Employment Site
□ Walk-in
□ Family/Friend
□ Internal Employee
□ Print Advertisement
If referred by DVR/DARS/DORS or VA, which office location? __________________________________________________________________
Skookum Employment Application
Page 4 of 11
HR AP 1.10
June 11, 2013
Employment Experience
(Start with your present or most recent job)
Employer
Dates Employed (Month/Year)
Hourly Rate/Salary (Starting - Final)
From:
To:
Job Title
Supervisor Name
$
□ Full Time
□ Part Time
Address
Phone Number(s)
Reason for Leaving:
□ Paid
□ Volunteer
May we contact this employer?
□ No
□ Yes
Duties Performed
Employer
Dates Employed (Month/Year)
Hourly Rate/Salary (Starting - Final)
From:
To:
Job Title
Supervisor Name
$
□ Full Time
□ Part Time
Address
Phone Number(s)
Reason for Leaving:
□ Paid
□ Volunteer
May we contact this employer?
□ No
□ Yes
Duties Performed
Employer
Dates Employed (Month/Year)
Hourly Rate/Salary (Starting - Final)
From:
To:
Job Title
Supervisor Name
$
□ Full Time
□ Part Time
Address
Phone Number(s)
Reason for Leaving:
□ Paid
□ Volunteer
May we contact this employer?
□ No
□ Yes
Duties Performed
Employer
Dates Employed (Month/Year)
Hourly Rate/Salary (Starting - Final)
From:
To:
Job Title
Supervisor Name
$
□ Full Time
□ Part Time
Address
Phone Number(s)
Reason for Leaving:
□ Paid
□ Volunteer
May we contact this employer?
□ No
□ Yes
Duties Performed
Skookum Employment Application
Page 5 of 11
HR AP 1.10
June 11, 2013
Reference Request
Applicant Name
Previous Employer
Name of Reference
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
Reference Request
Applicant Name
Previous Employer
Name of Reference
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 Information
Name of School
Location
Year of Graduation
Diploma/Degree
Awarded
Field of Study
Issue Date
Expiration Date
High School
College
Other
Licenses/Certifications
License/Certificate Type
State Issued
License/Certificate
Number
Driver License
□ No
□ Yes
□ No
□ Yes
Forklift Certification
□ No
□ Yes
CDL
Type:
Other
Please list:
Skookum Employment Application
Page 6 of 11
HR AP 1.10
June 11, 2013
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.
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, lifethreatening 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.
Skookum Employment Application
Page 7 of 11
HR AP 1.10
June 11, 2013
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:
APPLICANT INFORMATION: (Please type or print clearly)
Applicant's Name: __________________________________________________________
Last
First
Full Middle
Alias/Maiden Name: ________________________________________________________
Date of Birth: ___________________ Sex: _______________ Race: _________________
Month/Day/Year
Place of Birth: ______________________________________________________________
City
State
Social Security Number: ______________________________________________________
Driver License #/State Issued: _________________________________________________
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
Skookum Employment Application
_________________________________
Date
Page 8 of 11
HR AP 1.10
June 11, 2013
SKOOKUM 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.
Date: ____________________ Name (please print): ______________________________________________
Position Applied for: ______________________________________________________________________
Gender: □ Male □ Female
Ethnic Group: (Please check one or more of the descriptions below for the ethnic group with which you most identify)
□ Native American or Alaska 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
□ Two or more races: Any combination of two of the above
Employee Signature: ____________________________________________Date: _______________________
Skookum Employment Application
Page 9 of 11
HR AP 1.10
June 11, 2013
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
Skookum Employment Application
Page 10 of 11
HR AP 1.10
June 11, 2013
Sample Letter for Medical Provider
Skookum Employment Eligibility Determination
Our mission at Skookum is “Creating Opportunities for People with Disabilities”. Direct labor positions at
Skookum, require medical documentation of a significant disability. The disability documentation must
contain a diagnosis, severity of the diagnosis, impact of the diagnosis on the individual, treatment
plan/prescribed medications, and possible accommodations that Skookum can provide.
Must be on Medical Provider’s Letterhead
Today’s Date
Re: Patient First and Last Name
DOB: Date of Patient’s Birth
Dear Skookum:
This letter documents that Patient Name is diagnosed with:
Axis I:
Axis II:
Axis III:
List applicable diagnoses
List applicable diagnoses
List applicable diagnoses
These conditions are chronic, degenerative, progressive, etc.
This patient is being treated with list prescribed medications, treatment plans or prescribed counseling.
These conditions affect Patient Name in the following ways:
list effects of the diagnosed conditions and functional limitations resulting from diagnosed conditions
Patient Name would benefit from the following accommodations:
list accommodations
Sincerely,
Signature of Medical Provider
Printed name and credentials of Medical Provider
The diagnosis must be documented by a licensed medical or mental health professional:
Diagnosis
Mental Retardation
Mental Illness
or
Cognitive Impairment
or
Physical Impairment
Skookum Employment Application
Licensed Professional
Psychologist
Report in File
Psychological Evaluation
Psychiatrist or
Clinical Psychologist
Licensed Mental Health Counselor or
Psychiatric Mental Health Nurse Practitioner
(PMHNP)
Medical Physician (MD) or
Nurse Practitioner (NP) or
Physician Assistant (PA)
Psychiatric Evaluation
Page 11 of 11
Diagnostic Summary
Medical Report
HR AP 1.10
June 11, 2013