East Central Illinois Area Agency on Aging Employment Application

East Central Illinois Area Agency on Aging

Employment Application
We appreciate your interest in this agency. A clear understanding of your background and employment history will aid in matching your interests and abilities with our needs. Please complete the following form as thoroughly as possible. Incomplete applications will not be considered. Please put N/A (Not Applicable) in items rather than leaving them blank. If you have any written information you think would be helpful, please attach it to this form.
Date

MonthDayYear
Name
Phone Number
Email
example@example.com
Street Address/Apt No
City
State
Zip Code
Do you have a valid Driver's License?
Education
Name and Location of School
Graduated

YesNoStill Attending
Year Completed
Major/ Minor/ Honor/ Certification
Is your college transcript available to us?
Name and Location of School
Graduated

YesNoStill Attending
Year Completed
Employment

Begin with most recent. Please be specific in describing previous job experience with the aging population and/or persons who are developmentally disabled.
Company Name
Timeframe (mm/yy to mm/yy)
Company Address
Company Phone
Job Title
Supervisor
Major Duties
Reason Leaving
Company Name
Timeframe (mm/yy to mm/yy)
Company Address
Company Phone
Job Title
Supervisor
Major Duties
Reason Leaving
Company Name
Timeframe (mm/yy to mm/yy)
Company Address
Company Phone
Job Title
Supervisor
Major Duties
Reason Leaving
Other Pertinent Information: (l.e. Military Service, hobbies and interests, volunteering, etc)
What professional license or certificate do you hold
Have you ever worked for ECIAAA previously?
If yes, what years
Salary Expectations ($/hr)
Availability
Date available to start work

MonthDayYear
Date
References

Two employment references and one personal reference are required before you can be contacted for employment. Please notify your references that they will be contacted and that they should respond promptly. References from family members will not be accepted unless they relate to previous employment in a family business.
Employer Reference 1: Name
Phone Number
Email
example@example.com
Company Name
Job Title
Employer Reference 2: Name
Phone Number
Email
example@example.com
Company Name
Job Title
Personal Reference: Name
Phone Number
Email
example@example.com
Relationship to Applicant
The facts set forth in my application for employment are true and complete. I understand that if employed, false statements may be sufficient cause for my dismissal. You are hereby authorized to make any investigation of my employment record, educational training and references as may be necessary and relevant to the position applied for in this application.I hereby release the agency from any liability arising from disclosure of such information.
Signature

Clear
Date

MonthDayYear
Date
East Central Illinois Area Agency on Aging

EEO/Affirmative Action Employer
Should be Empty:

East Central Illinois Area Agency on Aging

Education

Employment

References