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 E-MAIL ADDRESS

Have you applied to WIRB within the past year? Do you need testing assistance such as a sign language  No  Yes If yes, when?______interpreter or reader?  No  Yes Check types of employment you will accept: Date you are available to begin work:  Full-time  Temporary  Part-time  Intermittent (On-Call) Are you currently employed? If yes, may we contact your employer?  No  Yes  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 WORD ______ Typing ______wpm  General Office Clerical ____  MS Excel ______ MS Outlook ___  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 membership, 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 State of Issuance Number, if applicable

Other than English, what languages do you know fluently? How did you learn of this employment opportunity? ______ Speak  Read  Write  Human Resources Dept.  Newspaper  Friend/Neighbor______ Speak  Read  Write  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 Quarter Semester Other Major Degree Awarded Year Received 1. From /

To / 2. From /

To / 3. 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 ( ) Your Title Months/Years Employed in this Position Total Months Hours Per Week Last Salary From / To / Immediate Supervisor’s Name Reason for Leaving Volunteer () No. of Employees Supervised  Specific Duties:

2. Previous Firm or Employer Employer’s Address Employer’s Phone Number ( ) Your Title Months/Years Employed in this Position Total Months Hours Per Week Last Salary From / To / Immediate Supervisor’s Name Reason for Leaving Volunteer () No. of Employees Supervised  Specific Duties:

WIRB is an Equal Opportunity Employer 2 Application for Employment 05-01-2011 091401002 WESTERN INSTITUTIONAL REVIEW BOARD, Inc. Application for Employment

3. Previous Firm or Employer Employer’s Address Employer’s Phone Number ( ) Your Title Months/Years Employed in this Position Total Months Hours Per Week Last Salary From / To / Immediate Supervisor’s Name Reason for Leaving Volunteer () No. of Employees Supervised  Specific Duties:

4. Previous Firm or Employer Employer’s Address Employer’s Phone Number ( ) Your Title Months/Years Employed in this Position Total Months Hours Per Week Last Salary From / To / Immediate Supervisor’s Name Reason for Leaving Volunteer () 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 WHY HAVE YOU SELECTED THIS PERSON AS A AND E-MAIL ADDRESS 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

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. PLEASE READ THE (_____ Initial here) FOLLOWING STATEMENTS CAREFULLY BEFORE Interviews are given on a competitive basis, using job related factors, after a written application has SIGNING TO INDICATE 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) YOUR UNDERSTANDING 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. OR B. Not Hispanic or Latino:  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