Dave and Gwen Broucek

mayo 25th, 2015

Dave and Gwen serve on SAM’s Senior Leadership team

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Let’s Talk!
Name*
First Last
Email*

Phone*
Date of Birth*
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Gender*
Male
Female
Are you a US Citizen?*

Yes

No
If no, what is your country of citizenship?
Spouse Name (if applicable)
Nombre Apellidos
Spouse Email (if applicable)

I'm Interested in...*
Short-Term (2 month -1 year)
Mid-Term (1-2 years)
Long-Term (2+ years)
Internship (8-15 weeks)
Other
Other Ministry
Tell us about your interest in serving with South America Mission.*
How did you find out about South America Mission?*
Conference / Event
Church
Website
School or College
SAM Missionary or Staff
Instagram
Facebook
LinkedIn
Other
Other Source
Updates from South America Mission
I do not want to receive updates from South America Mission
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Facebook
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Short-Term Team Participant Form
PARTICIPANT INFORMATION (completed by participant or authorized guardian)
Please indicate the organization or team name of the team you will be participating with:*
Participant Name (as it appears on passport)*
Nombre Segundo nombre Apellidos
Address*
Dirección Ciudad Provincia Código Postal

Email Address*

Mobile Phone Number*
Passport #*
Passport Issuing Country*
Passport Expiration Date*
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Date of Birth*
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T-Shirt Size*

S

M

L

XL

XXL
Do you have any physical conditions that might require special accommodations or on this trip? If yes, please explain*
Yes
No
Special accommodations for physical conditions
Do you have any known allergies? If yes, please list below*
Yes
No
Known Allergies
Are you currently taking any prescription medications? If yes, please list below.*
Yes
No
Prescription medications list
Do you have any dietary restrictions? If yes, please explain.*
Yes
No
Dietary restrictions
EMERGENCY CONTACT
Emergency Contact Name*
Relationship*
Mobile Phone Number*
If you are under 18 years, please type the email of a parent and/or guardian.
PHOTO RELEASE
I give South America Mission permission to use my likeness in photographs, video recordings, and other digital media in any and all of its publications, including print publications, websites, and social media platforms, without payment or other consideration.*
Yes
No
Name*
Date*
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Signature*
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Company
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South America Mission is privileged to carry out Christian ministry that results in “redeemed lives, beautiful churches, and transformed communities.” Towards that end, we are continually developing a staff team of competence, character, and commitment to serving others. We desire to have a team that joyfully works together with passion for our mission. Thank you for your interest in being part of our team and taking this first step of exploration with South America Mission.
BASIC INFORMATION
Full Legal Name*
Nombre Segundo nombre Apellidos
Address*
Dirección Ciudad Provincia Código Postal

Phone*
Email*

WORK INTEREST
Role(s) Interested In*
Employment Desired*

Full-Time

Part-Time

Temporary
Available Start Date*
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Desired Annual Salary*
Do you know anyone who has been or is still employed by our organization? If yes, please list name(s):*
Why are you interested in working with South America Mission?*
Have you read, and do you agree with Our Beliefs?*

Yes

No
EDUCATION
Please list up to three post-secondary education experiences, starting with the most recent. This may include college, university, seminary, or formal training programs.
Did you earn a high school diploma or equivalent (GED)?*

Yes

No
1. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

Yes

No

In Progress
2. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

Yes

No

In Progress
3. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

Yes

No

In Progress
EMPLOYMENT HISTORY
Please list up to 3 previous employers, starting with your most recent.
Employer Name*
Job Title*
Start Date*
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End Date
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Responsibilities / Achievements*
Reason for leaving*
Supervisor’s Name & Title*
May we contact him/her?*
Yes
No
Work Phone
Email

Employer Name
Job Title
Start Date
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End Date
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Responsibilities / Achievements
Reason for leaving
Supervisor’s Name & Title
May we contact him/her?
Yes
No
Work Phone
Email

Employer Name
Job Title
Start Date
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End Date
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Responsibilities / Achievements
Reason for leaving
Supervisor’s Name & Title
May we contact him/her?
Yes
No
Work Phone
Email

LANGUAGES
Please describe any languages you speak and your level of fluency.
FAITH AND PASSIONS
Current Church You Attend*
City, State*
How long have you attended this church?*
What is / has been your church involvement?*
Provide us with the name and contact information of a pastor or spiritual mentor who can speak to your Christian character.*
This section is reserved for you to speak into your faith, passions, and additional skills that you would like to share.
RESUME & COVER LETTER
Please upload a current resume (PDF).*
Tamaño máximo de archivo: 50 MB.
Please upload a cover letter (PDF).*
Tamaño máximo de archivo: 50 MB.
APPLICANT INFORMATION
Do you identify as a protected veteran?
Yes
No
I prefer not to answer.
Have you ever been convicted of a felony?
Yes
No
If yes, please kindly explain:
Have you ever been asked to resign or been terminated from a previous job?
Yes
No
If yes, please kindly explain:
Have you ever been convicted of child abuse, sexual abuse, or any crime involving harm to a minor?
Yes
No
If yes, please kindly explain:
South America Mission is both an equal opportunity employer and a faith-based religious organization. We conduct hiring without regard to race, color, ancestry, national origin, citizenship, age, sex, marital status, parental status, membership in any labor organization, political ideology, or disability of an otherwise qualified individual. The status of South America Mission as an Equal Opportunity Employer does not prevent the organization from hiring personnel based on their religious beliefs so that all personnel share the same religious commitment. Pursuant to the Civil Rights Act of 1964, Section 702 (42 U.S.C. [§] 2000e[- ]1(a)), South America Mission has the right to hire only candidates who whole-heartedly and without reservation agree with South America Mission's Beliefs.
SIGNATURE
Consent*
I certify that the statements made in this application are true.*
Consent*
I authorize South America Mission to seek information from the references sources and employers listed on this application.*
Date
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Signature*
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Dave and Gwen Broucek

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Short-Term Team Participant Form

PARTICIPANT INFORMATION (completed by participant or authorized guardian)

EMERGENCY CONTACT

PHOTO RELEASE

BASIC INFORMATION

WORK INTEREST

EDUCATION

EMPLOYMENT HISTORY

LANGUAGES

FAITH AND PASSIONS

RESUME & COVER LETTER

APPLICANT INFORMATION

SIGNATURE