Form

Form
Armstrong County Community Action of Pennsylvania

Application for Employment
The Armstrong County Community Action of Pennsylvania (ACCAP) is an equal opportunity employer committed to maintaining a diverse and inclusive mission-driven workforce. We maintain that policy in recruitment, hiring, career advancement, and all other human resource practices. Your job-related experience and other qualifications will be considered without discrimination on grounds of age, race, color, religion, sex, gender, physical or mental disability, sexual orientation, Veteran, or other protected status. All information in this application will be treated confidentially.
TemporaryPart-TimeFull-Time
Position applied for:
Date:

MonthDayYear
Date
Name:

Last NameFirst NameMiddle Name
Address:

Street Address

Apartment/Unit#

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone/Pager:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
YesNo
If you have applied for employment at ACCAP, please provide the month and year.
YesNo
YesNo
Date Available to Work:
Minimum Salary Requirements
$blanks/hour
$ blank/year
Employment History

Please list your three most recent employers, assignments, or volunteer activities. Please attach any explanations for gaps in employment or additional employers of relevance.
Employer 1
Telephone- Employer 1
Please enter a valid phone number.Format: (000) 000-0000.
Dates Employed at Employer 1
From: blanks
To: blank
Address- Employer 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title and Primary Duties- Employer 1
Immediate Supervisor (Name & Title): Employer 1
YesNoLater
Reason for Leaving- Employer 1
Annual Salary- Employer 1
Starting: blanks
Ending: blank
Employer 2
Telephone- Employer 2
Please enter a valid phone number.Format: (000) 000-0000.
Dates Employed- Employer 2
From: blanks
To: blank
Address-Employer 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title and Primary Duties- Employer 2
Immediate Supervisor (Name and Title)-Employer 2
YesNoLater
Reason for Leaving- Employer 2
Annual Salary- Employer 2
Starting: blanks
Ending: blank
Employer 3
Telephone- Employer 3
Please enter a valid phone number.Format: (000) 000-0000.
Dates Employed- Employer 3
From: blanks
To: blank
Address- Employer 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title and Primary Duties-Employer 3
Immediate Supervisor (Name and Title)-Employer 3
YesNoLater
Reason for Leaving-Employer 3
Annual Salary- Employer 3
Starting: blanks
Ending: blank
Education Background
Name and City of High School
High School: Number of Years Attended
YesNo
Degree Received
Course/Major
Name and City of College (if none, mark N/A)
College: Number of Years Attended
YesNo
Degree Received
Course/Major
Name and City of Post-Graduate School (if none, mark N/A)
Post-Graduate: Number of Years Attended
YesNo
Degree Received
Course/Major
Name and City of Trade, Business or Other School (if none, mark N/A)
Trade/Business School: Number of Years Attended
YesNo
Trade/Business School: Degree Received
Trade/Business School: Course/Major
Employment References

Please list names, titles, and contact information for three business/work references. These references should be professional references. Please do not list personal friends or relatives.
Reference 1: Name and Title
Reference 1: Telephone
Reference 1: Email
Reference 1: Relationship
Reference 1: Organization
Reference 2: Name and Title
Reference 2: Telephone
Reference 2: Email
Reference 2: Relationship
Reference 2: Organization
Reference 3: Name and Title
Reference 3: Telephone
Reference 3: Email
Reference 3: Relationship
Reference 3: Organization
Professional Memberships
Please list professional, business, or civic associations, and any offices held that are related to the position for which you are applying.
Please list any special accomplishments, publications, awards, or other relevant information relating to the position that you are applying for that you would like us to consider.
Please read carefully before signing:

I authorize investigation of all statements contained in the application. I understand that misrepresentation or omission of facts is cause for dismissal. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.
*If you are submitting this application electronically, completion of the 'Applicant Signature' box shall constitute your understanding of and agreement to the terms and conditions of the application.*
Applicant Signature

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

Form

Armstrong County Community Action of Pennsylvania

Employment History

Education Background

Employment References

Please read carefully before signing: