NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP

NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP

An Equal Opportunity Employer
APPLICATION FOR EMPLOYMENT
We consider applicants for employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. We will give this application every consideration. However, in accepting it, Northeast Nebraska Community Action Partnership makes no commitment of employment to the applicant.

Federal law obligates us to provide reasonable accommodation to the known disabilities of applicants and employees, unless to do so would pose an undue hardship. Please let us know if you need an accommodation to complete the application process.

It is also the policy of this agency to have the option of conducting pre-employment screening before a job offer is made. If a job offer is made, employment may be contingent upon the successful completion of drug and alcohol testing and medical examination, which may include providing body substance samples.

We are an at-will employer, meaning that either the employer or the employee may end the employment relationship at any time and for any or no reason.
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone
Cell Phone
Social Security Number (optional)
Email Address*
example@example.com
Position Applying for
Are you 18 years of age or older*

YesNo
If Hired, can you provide written evidence that you are authorized to work in the U.S.

YesNo
Have you filed an application here before?

YesNo
Give Date of previous application
Have you ever been employed here before

YesNo
Give Date of previous employment
Are you employed now?

YesNo
May we contact your present employer

YesNo
Are you on lay-off and subject to recall

YesNo
Can you travel if a job requires it

YesNo
If hired, what date would you be available for work

MonthDayYear
Date
Expected Salary
Are you available to work

Full-TimePart-TimeTemporary
What Days

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Have you ever been convicted of a felony

YesNo
Conviction will not necessarily disqualify applicant from employment. The recency, severity and pertinence of the conviction to the job will all be considered. Please Explain
Veteran of U.S. Military Service

YesNo
What was your Branch, Rank and Type of service

Education

	Name/Location	Course of Study	Years Completed	Title of Diploma or Degree
High School
College
Graduate Study
Other

Indicate any foreign languages you speak, read, and/or write.

	FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

Describe any specialized training, apprenticeship, skill and extra-curricular activities including professional, trade, business, or civic activities and offices held. You may exclude memberships that would reveal gender, race, religion, national origin, age, ancestry, disability, or other protected status.
Describe any job-related training received in the United States military.
Other qualifications Summarize special job-related skills and qualification acquired from employment or other experience.
EMPLOYMENT RECORD
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, gender, national origin, or other protected status.
1. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
2. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
3. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
4. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
5. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
6. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
7. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving
8. Employer Name
Employer Address
Date Employed Started
Date Employed Left
Telephone
Job Title
Rate of Pay Starting
Rate of Pay Ending
Work Performed
Supervisor
Reason for Leaving

References (Do no include relatives)*

	Name	Phone #	Address	Best Time to Contact	Years Known
1.
2.
3.

APPLICANT’S STATEMENT
I authorize the investigation of all statements contained in this application for employment including my work and personal history and verification of all data given on this application, on related documents and in interviews as may be necessary in arriving at an employment decision and release from all liability any persons or employers supplying such information. I also release Northeast Nebraska Community Action Partnership from all liability that might result from making the investigation.

I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or any required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

I agree, if I am offered and accept a position, to conform to all existing and future Northeast Nebraska Community Action Partnership rules and regulations and I understand that NENCAP reserves the right to change wages, hours and working conditions as deemed necessary. I ALSO UNDERSTAND THAT, IF HIRED, MY EMPLOYMENT WILL BE AT-WILL, MEANING THAT EITHER PARTY CAN END THE EMPLOYMENT RELATIONSHIP AT ANY TIME, FOR ANY OR NO REASON and this policy cannot be changed verbally or in writing, unless the change is specifically authorized in writing by the Executive Director of this organization. I also understand that this application is not an employment contract.

I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.

This application for employment shall be considered active for a period of time not to exceed one year.

I have read and reviewed the information provided in this application and the above statements. By signing this application for employment I certify that I understand all parts of it and have answered all questions completely and fully.
Your Signature*

Clear
Date*

MonthDayYear
Date
Voluntary Self-Identification

(Confidential-For Statistical Use Only)
Applicants are considered for positions, and employees are treated during employment without regard to race, color, religion, sex, age, marital status, national origin, disability, veteran status, sexual orientation or any other classification protected by federal, state or local law.

Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment. This information is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.
COMPLETION OF THIS FORM IS VOLUNTARY
Date

MonthDayYear
Date
Position(s) applied for
Referral Source

Newspaper AdFriendWalk-InWorkforce DevelopmentRelativeCollege Career CenterAgency WebsiteOther
Name
Phone
Address
City
State
Zip Code
Date of Birth

MonthDayYear
Date
AFFIRMATIVE ACTION DATA
Check One

MaleFemale
RACE/ETHNIC GROUP - CHECK ONE OF THE FOLLOWING:

Hispanic or Latino - A Person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.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 AfricaNative Hawaiian or Other Pacific Islander (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 Subcontinent, 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 of who maintain tribal affiliation or Community attachment.Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.Race missing or unknown - Applies to Applicants only, where a resume or application that is screened is received without any racial or ethnic identification and no further contact is made with the applicant.
VETERAN STATUS - CHECK ALL THAT APPLY

I am not a VeteranI am a VeteranI am a Vietnam Era Veteran (August 5, 1964 - August 7, 1975)
Should be Empty:

NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP

APPLICATION FOR EMPLOYMENT

EMPLOYMENT RECORD

APPLICANT’S STATEMENT

Voluntary Self-Identification

COMPLETION OF THIS FORM IS VOLUNTARY

AFFIRMATIVE ACTION DATA