City Impact Staff Application

Step 1 of 6

Name*
First Last
Gender
- Female
- Male
- Prefer not to say
Phone
Email*
Address
Street Address Address Line 2 City State ZIP Code
What position(s) are you interested in applying for?*
Birthday
MM slash DD slash YYYY
Employment Status
- Unemployed
- Employed
- Retired
- Student
Permanent Address
If you’re a student please give us a permanent address

Street Address Address Line 2 City State ZIP Code
Employer Name
Employer Address
Street Address Address Line 2 City State ZIP Code
Emergency Contact Name
First Last
Emergency Contact Relationship
Emergency Contact Phone
Emergency Contact Address
Street Address Address Line 2 City State ZIP Code

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City Impact is a Christian, humanitarian organization seeking to meet physical and spiritual needs of under-resourced youth in Lincoln. Because of the unique nature of our ministry, it’s important that our staff feel comfortable within our Christian ministry. With this in mind, please answer the following.

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References
List those familiar with your capabilities (do not list relatives). If possible, we prefer to have a combination of friend, employer, teacher, and/or fellow worker. IMPORTANT: Three (3) references are required. Please provide an address or email address for each reference.
Reference One
Name*
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email*
Years known
Organization
Position
Reference Two
Name*
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email*
Years known
Organization
Position
Reference Three
Name
First Last
Phone
Address
Street Address Address Line 2 City State ZIP Code
Email
Years known
Organization

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City Impact Staff Agreement
I acknowledge that if accepted as a City Impact staff member, I agree to abide by the rules and regulations of City Impact..*
- Confirm
I have not been convicted within the past 10 years of any felony or misdemeanor classified as an offense against a person or family, of public indecency or a violation involving a state or federally controlled substance.*
- Confirm
I am not currently under indictment.*
- Confirm
I give permission for City Impact to perform a check of my background including Social Security Number verification, Nationwide Criminal Record search, Statewide Criminal Record search, Nebraska Adult Abuse Registry search and Nebraska Child Abuse Registry search. I understand that I do not have to agree to this background check, but the refusal to do so may exclude me from consideration for some types of work. I understand that information collected during this background check will be limited to that appropriate to determining my suitability for particular types of work and that all such information collected during the check will be kept confidential.*
- Confirm
I give permission for City Impact to contact my identified references. I understand that by contacting these individuals they will be asked to give their full and honest evaluation of my suitability of the described work and such other information as they deem appropriate.*
- Confirm
I understand that City Impact reserves the right to take my picture and use it for promotional purposes, unless check marked in the statement below.*
- Confirm
- I do NOT wish to have photographs I might be in, published for the promotion of City Impact
I understand that City Impact reserves the right to deny application to any person and to terminate a part-time staff from the program. This program does not accept responsibility for relationships when meeting outside of program.

I have read the above statements and agree to the contents. To the best of my knowledge and belief, all statements in this application are true and accurate.
Signature
Date
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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Area	Age Group

Step 1 of 6

References

Reference One

Reference Two

Reference Three

City Impact Staff Agreement