WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Please submit this completed Application for Employment together with a resume and a cover letter.
Incomplete submissions will not be considered for employment.
Part 1. GENERAL INFORMATION
POSITION (job title for which you are applying)
LAST FOUR DIGITS OF SOCIAL SECURITY NO.
NAME (last, first, and middle initial)
HOME TELEPHONE
MAILING ADDRESS (include apartment number, if any)
WORK (or message) TELEPHONE
CITY
COUNTY
STATE
ZIP
Have you applied to WIRB within the past year?
 No  Yes If yes, when?__________________
Do you need testing assistance such as a sign language
interpreter or reader?
 No  Yes
Date you are available to begin work:
Check types of employment you will accept:
 Full-time
 Part-time
E-MAIL ADDRESS
 Temporary
 Intermittent (On-Call)
Are you currently employed?
 No  Yes
If yes, may we contact your employer?
 No  Yes  Notify me prior to contacting my current employer
SPECIALIZED SKILLS (Check all that apply and indicate number of years experience or training, if any.)
 PC _________
 MS Outlook ___
 MS WORD _________  Typing ______wpm  General Office Clerical ____  MS Excel ________
 Proofreading ______  Customer Service ___  Supervisory Skills _______  MS Access ______
Part 2. BACKGROUND INFORMATION
Please list any licenses, certifications, or memberships that you wish to have considered. For example: registered nurse license, bar memb
etc:
If more space is needed attach additional sheets.
License, Certificate, or Membership
Expiration Date
State of Issuance
Number, if applicable
License, Certificate, or Membership
Expiration Date
Other than English, what languages do you know fluently?
_____________________  Speak
_____________________  Speak
 Read
 Read
 Write
 Write
State of Issuance
Number, if applicable
How did you learn of this employment opportunity?
 Human Resources Dept.  Newspaper  Friend/Neighbor_________
 Employment Agency
 Internet
 Other ____________________
Have you been convicted of a crime within the past ten (10) years?  Yes  No
Are you currently, or have you ever been, debarred, excluded, suspended, and/or declared ineligible by the U.S. Department of
Health and Human Services, U.S. Food and Drug Administration, or any other state or federal agency from receiving federal or
state money or contracts (pursuant to the following, or any other, laws 21 USC 306(a), or (b), 21 U.S.C. 335a, 48 C.F.R. 9.406
or 9.407?  Yes  No
Is any U.S. Department of Health and Human Services, U.S. Food and Drug Administration, or any other state or federal agency
action or investigation relating to debarment, exclusion, suspension, and/or a declaration of ineligibility from receiving federal
or state money or contracts currently pending or threatened against you? (Pursuant to the following, or any other, laws 21
U.S.C. 306 (a) or (b), 21 U.S.C. 335 a, 48 C.F.R. 9.406 or 9.407)?  Yes
 No
If any of the questions are answered “yes”, please attach on explanation
WIRB is an Equal Opportunity Employer
1
Application for Employment 05-01-2011
091401002
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Part 3. EDUCATION
Are you a high school graduate, or have you passed a general education development (GED) test?
 Yes  No
If no, highest grade completed: _______________
List post-high school training, including college, business school, military training, and other relevant education.
If more space is needed attach additional sheets.
Month and Year
Credits Earned
Type of
School Name and Location
Attended
Major
Degree Awarde Year Received
Quarter Semester Other
1.
From
/
2.
To
From
/
/
3.
To
From
/
/
To
/
Part 4. EMPLOYMENT HISTORY
This section must be completed entirely. Do not substitute a resume. List all work experience, paid and unpaid beginning with your
current or most recent job during the last ten years. Include military experience as well as volunteer jobs that you wish to have
considered as part of your qualification for the posting you are seeking. If you need more space, copy the blank form or attach
additional sheets.
1. Present or Last Employer
Employer’s Address
Employer’s Phone Number
(
)
Months/Years Employed in this Position Total Months Hours Per Week Last Salary
Your Title
From
Immediate Supervisor’s Name
/
To
/
Volunteer ()

Reason for Leaving
No. of Employees Supervised
Specific Duties:
2. Previous Firm or Employer
Your Title
Immediate Supervisor’s Name
Employer’s Address
Months/Years Employed in this Position Total Months
From
/
To
/
Volunteer ()
Reason for Leaving

Employer’s Phone Number
(
)
Hours Per Week
No. of Employees Supervised
Specific Duties:
WIRB is an Equal Opportunity Employer
2
Application for Employment 05-01-2011
Last Salary
091401002
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
3. Previous Firm or Employer
Your Title
Immediate Supervisor’s Name
Employer’s Address
Employer’s Phone Number
(
)
Months/Years Employed in this Position Total Months
From
/
To
/
Volunteer ()
Reason for Leaving

Hours Per Week
Last Salary
No. of Employees Supervised
Specific Duties:
4. Previous Firm or Employer
Your Title
Immediate Supervisor’s Name
Employer’s Address
Employer’s Phone Number
(
)
Months/Years Employed in this Position Total Months
From
/
To
/
Volunteer ()
Reason for Leaving

Hours Per Week
Last Salary
No. of Employees Supervised
Specific Duties:
Part 5. REFERENCES:
Include only individuals familiar with your work ability. Do not include relatives or current WIRB employees.
NAME
CONTACT NUMBER
AND E-MAIL ADDRESS
WHY HAVE YOU SELECTED THIS PERSON AS A
CHARACTER REFERENCE?
1.
2.
3.
WIRB is an Equal Opportunity Employer
3
Application for Employment 05-01-2011
091401002
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Part 6. REFERENCE CHECKS/VERIFICATION OF EMPLOYMENT
PLEASE READ THE
FOLLOWING STATEMENTS
CAREFULLY BEFORE
SIGNING TO INDICATE
YOUR UNDERSTANDING
WIRB® is an equal opportunity employer and does not discriminate on the basis of gender, age, race
and color, religion, marital status, national origin, gender identity, disability or veteran status.
(_____ Initial here)
Interviews are given on a competitive basis, using job related factors, after a written application has
been received and reviewed. Because of the large number of applications received, not everyone who
applies for a vacant position will be interviewed. (_____Initial here)
I understand that, if selected, I will be required to provide proof of my identity and my legal ability to
work in the United States prior to actual employment with WIRB®. (_____Initial here)
I certify that I have answered truthfully and have not knowingly withheld any information relative to my
application. I understand that a misrepresentation or material omission on this application will result in
my being eliminated from future consideration. I further understand that, if accepted for employment,
any misrepresentation or material omission, which becomes known to WIRB®, will result in immediate
termination of my employment. (_____Initial here)
I authorize all previous employers and supervisors, including all persons with and for whom I have
worked, to provide the WIRB® representatives any and all information regarding me and my previous
employment. I release WIRB®, and all previous employers and supervisors from liability for any
damages that may result from furnishing information to WIRB®. (_____ Initial here)
I understand I must comply with the instructions, rules and policies of WIRB®. My employment and
compensation, if I am accepted for employment, can be terminated at any time, with or without cause
and with or without notice, at the option of either the company or myself. (_____Initial here)
____________________
____________________________________
Date (month/day/year )
Signature
®
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
1019 39th Avenue SE Suite 120 • Puyallup, WA 98374-2115
(360) 252-2500 • FAX (360) 252-2878
WWW.WIRB.COM
WIRB is an Equal Opportunity Employer
4
Application for Employment 05-01-2011
091401002
Company use only
Job Group: ________
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Affirmative Action Information Sheet – Veterans and Disabled
This organization is an Equal Opportunity Employer. To ensure equal employment opportunity, we ask your voluntary
cooperation in responding to the questions below.
This information will be treated as confidential, and will be available only to authorized personnel. Please
review the Affirmative Action definitions below.
Name (Last, First, Middle Initial)
Date of Birth
Social Security Number
1.
Have you ever been on active duty in the U.S. Armed Forces?
 No
 Yes Dates __________________
 Vietnam-era Veteran
 Disabled Veteran: Percent of disability: _______%
2.
Do you have a physical, sensory, or mental condition that substantially limits any of your major life
functions, such as working, caring for yourself, walking, doing things with your hands, seeing,
hearing, speaking, learning?
 Yes  No
3.
Do you have a physical, mental, or other health condition that has lasted six (6) or more months and
which limits the kind or amount of work you can do at this job?
 Yes  No
I certify that this information is true and accurate to the best of my knowledge.
________________________________________ ____________________________________________
Date
Your Signature
Affirmative Action Definitions
Disabilities. For Affirmative Action purposes, people with disabilities are person with permanent physical, mental, or
sensory impairment which substantially limits one or more major life activities. Physical, mental, or sensory
impairment means: (a) any physiological or neurological disorder or condition, cosmetic disfigurement, or anatomical
loss affecting one or more of the body systems or functions; or (b) any mental or psychological disorders such as
mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The
impairment must be material rather than slight, and permanent in that it is seldom fully corrected by medical
replacement, therapy or surgical means.
Disabled veteran. A person entitled to disability compensation under laws administered by the U.S. Department of Veteran
Affairs for disability rated at 30 percent or more, or a person whose discharge or release from active duty was for a
disability incurred or aggravated in the line of duty.
Vietnam-era veteran. A person who served on active duty for a period of more than 180 days, any part of which occurred
between August 5, 1964, and May 7, 1975, and was discharged or released from duty with other than a
dishonorable discharge.
WIRB is an Equal Opportunity Employer
5
Application for Employment 05-01-2011
091401002
Company use only
Job Group: ________
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Affirmative Action Information Sheet
This organization is an Equal Opportunity Employer. To ensure equal employment opportunity, we ask your voluntary
cooperation in responding to the questions below.
This information will be treated as confidential, and will be available only to authorized personnel. Please review the
Affirmative Action definitions on the following page.
Name (Last, First, Middle Initial)
Date of Birth
Social Security Number
A.
 Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American or other
Spanish culture or origin regardless of race.
B.
Not Hispanic or Latino:
OR
 White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa
 Black or African American (Not Hispanic or Latino)- A person having origins in any of the black racial
groups of Africa
 Native Hawaiian or Other Pacific Islanders (Not Hispanic or Latino) – A person having origins in any
of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
 Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Sub continental, including, for example Cambodia, China, India, Japan, Korea,
Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
 American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the
original peoples of North and South America (including Central America), and who maintain tribal affiliations or
community attachment
 Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the
above five racial/ethnical groups. If you check this box, please list the single racial/ethnic group above
with which you most closely identify: ____________________________________________
C.
Are you
 Female
 Male
I certify that this information is true and accurate to the best of my knowledge.
________________________________________ ____________________________________________
Date
Your Signature
WIRB is an Equal Opportunity Employer
6
Application for Employment 05-01-2011
091401002
WESTERN INSTITUTIONAL REVIEW BOARD, Inc.
Application for Employment
Affirmative Action Definitions
American Indian or Alaskan Native. A person with origins in any of the original peoples of North America and who
maintains cultural identification through documented tribal affiliation or community recognition.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Sub
continental, including, for example Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam
Black/African-American. A person with origins in any of the Black racial groups of Africa.
Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin
regardless of race. For example, persons from Brazil, Guyana, or Surinam would be classified according to their
race and would not necessarily be included in the Hispanic category. This category does not include persons from
Portugal, who should be classified according to race.
Native Hawaiian or Other Pacific Islanders. A person having origins in any of the peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
White A person with origins in any of the original peoples of Europe, North Africa, or the Middle East.
WIRB is an Equal Opportunity Employer
7
Application for Employment 05-01-2011
091401002