Mid-Delta Community Services, Inc.
Application for Employment
All applicants are given consideration without regard to race, color, Religion, sex, national origin, age, veteran status or disability.
PERSONAL
Name
First Name
Middle Initial
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone
Format: (000) 000-0000.
City, State, Zip,
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail Address:
example@example.com
Business Telephone
Format: (000) 000-0000.
Have you ever applied for employment with us?
Yes
No
If yes, Month and Year
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location
Social Security #
List relatives employed by Mid-Delta (Name and relation)
Position Desired
Are you legally eligible for employment in the United States?
Yes
No
Pay Expected
In case of emergency, notify (name, relation, address & phone number)
When will you be available to begin work?
EDUCATION
Rows
Name and Location
Course of Study
No. of Years Completed
Did You Graduate? Yes
Did You Graduate? No
Date
Degree or Certification
High School/GED
Business/Trade/Technical
College Graduate/Classes/Degree
Graduate School
List any other skills or training here which are relevant to the position for which you are applying:
MILITARY
U S Military?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rank
Present Membership in Guard Reserves?
Yes
No
REFERENCES
(Give the names of three persons not related to you, whom you have known at least three (3) years)
References listed below
Must
have
Complete and Correct Mailing address, Zip Code, and Telephone Number
1. Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
2. Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
3. Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Format: (000) 000-0000.
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EMPLOYMENT
Please give accurate, complete full-time and part-time employment record.
Start with your present or most recent employer.
Company Name
Telephone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed - (State month and year) From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Supervisor
First Name
Last Name
Full-time or Part-time?
Last pay rate
State Job Title and Describe Your Work
Reason for Leaving
Company Name
Telephone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed - (State month and year) From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Supervisor
First Name
Last Name
Full-time or Part-time?
Last pay rate
State Job Title and Describe Your Work
Reason for Leaving
Company Name
Telephone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed - (State month and year) From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Supervisor
First Name
Last Name
Full-time or Part-time?
Last pay rate
State Job Title and Describe Your Work
Reason for Leaving
Are you presently employed?
Yes
No
If so, may we contact your present employer?
Yes
No
DO NOT CONTACT
Employer Number(s)
Reason
CRIMINAL RECORD
Have you ever been convicted for child sexual abuse, child abuse or neglect or a violent felony?
Yes
No
Within the past five (5) years, have you had any felony conviction for:
Drugs?
Yes
No
Substance Abuse?
Yes
No
Sexual offense?
Yes
No
Any crime of violence?
Yes
No
MDCS (5/14)
PER-006 (b)
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READ CAREFULLY BEFORE SIGNING
I AUTHORIZE VERIFICATION OF ALL STATEMENTS CONTAINED HEREIN, INCLUDING, BUT NOT LIMITED TO, REFERENCES LISTED AND FORMER EMPLOYERS TO RELEASE ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT, WHETHER POSITIVE OR NEGATIVE. I HEREBY RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO MID-DELTA COMMUNITY SERVICES, INC.
I UNDERSTAND THAT I AM APPLYING FOR AN “AT-WILL” EMPLOYMENT POSITION AND THAT ANY OFFER OF EMPLOYMENT TO ME IS CONTINGENT UPON MY AGREEMENT TO ABIDE BY THE LAWS OF THE STATE OF ARKANSAS AND THE RULES, REGULATIONS AND POLICIES OF MID-DELTA COMMUNITY SERVICES, INC.
I UNDERSTAND AND AGREE THAT I MAY BE REQUIRED TO TAKE A PHYSICAL EXAMINATION AT ANY TIME DURING MY EMPLOYMENT TO DETERMINE IF I AM DRUG/ALCOHOL FREE, FREE OF COMMUNICABLE DISEASES, AND PHYSICALLY FIT FOR THE JOB I WILL PERFORM.
NOTE: 1) SAFETY-SENSITIVE JOB APPLICANTS ARE REQUIRED TO UNDERGO PREEMPLOYMENT DRUG AND ALCOHOL TESTING.
2) CRIMINAL BACKGROUND RECORD CHECKS ARE REQUIRED FOR ALL CHILD CARE JOB APPLICANTS.
I HEREBY CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION FOR EMPLOYMENT ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MDCS (5/14)
PER-006 (c)
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ARKANSAS TRAFFIC VIOLATION RELEASE
I AUTHORIZE THE OFFICE OF DRIVER SERVICES TO RELEASE MY TRAFFIC VIOLATION RECORD TO MID-DELTA COMMUNITY SERVICES, INC. AND IT'S INSURANCE CARRIER. THIS RELEASE SHALL REMAIN IN FULL FORCE AND EFFECT FOR THE NEXT FIVE (5) YEARS, UNLESS A FORMAL WITHDRAWAL IS FILED BY ME.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Arkansas Driver's License Number
*
Mailing Address:
Mid-Delta Community Services, Inc.
P.O. Box 745
Helena, AR 72342
MDCS (5/14)
PER-006 (d)
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