Employment Application
Community Action, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
Full Name
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First Name
Middle Name
Last Name
Current Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
E-mail
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Education
Have you completed High School?
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Yes
No
Select Last Year Attended:
Please Select
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
High School Name, City, and State:
Major Subject:
Degree:
Did you graduate?
Yes
No
Did you attend college?
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Yes
No
Select Last Year Attended:
Please Select
1 Yr
2 Yrs
3 Yrs
4 Yrs
College Name, City, and State:
Major Subject:
Degree:
Did you graduate?
Yes
No
Did you attend graduate school?
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Yes
No
Select Last Year Attended:
Please Select
1 Yr
2 Yrs
3 Yrs
4 Yrs
College Name, City, and State:
Major Subject:
Degree:
Did you graduate?
Yes
No
Did you attend a Trade/Vo-Tech School?
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Yes
No
Select Last Year Attended:
Please Select
1 Yr
2 Yrs
3 Yrs
4 Yrs
Trade/Vo-Tech Name, City, and State:
Major Subject:
Degree:
Did you graduate?
Yes
No
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General Information
Enter the Job Position(s) you are applying for:
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Type of employment desired:
*
Please Select
Full-Time
Part-Time
Temporary
Select 'yes' or 'no' to each question below.
Rows
Yes
No
Are you 18 years or older?
If you are under 18, can you provide proof of your eligibility to work?
Are you legally eligible for employment in the United States? (If offered employment, you will be required to provide documentation to verify eligibility)
Are you currently employed?
If 'yes', may we contact your current employer for a reference?
Are you a former Head Start student or a former/current Head Start parent?
Have you filed an application with us before?
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Yes
No
If yes, give approximate date:
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Month
/
Day
Year
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Have you ever been employed with us?
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Yes
No
If yes, give date(s) and position(s):
On what date would you be able to report to work if offered this position?
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-
Month
-
Day
Year
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Employment Experience
Start with your present or most recent position. Complete all information for each position you have held. NOTE: Do not write, "See Resume"- your application will not be considered complete.
Name of Employer:
Phone Number
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Area Code
Phone Number
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name:
Employed from:
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Month
-
Day
Year
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Employed to:
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Month
-
Day
Year
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Rate of Pay:
Beginning Salary:
Ending Salary:
Your Position/Title:
Describe the work performed:
Reason for Leaving:
Name of Employer:
Phone Number
-
Area Code
Phone Number
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name:
Employed from:
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Month
-
Day
Year
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Employed to:
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Month
-
Day
Year
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Rate of Pay:
Beginning Salary:
Ending Salary:
Your Position/Title:
Describe the work performed:
Reason for Leaving:
Name of Employer:
Phone Number
-
Area Code
Phone Number
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name:
Employed from:
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Month
-
Day
Year
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Employed to:
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Month
-
Day
Year
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Rate of Pay:
Beginning Salary:
Ending Salary:
Your Position/Title:
Describe the work performed:
Reason for Leaving:
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Additional Qualifications
Indicate any languages, other than English, you can read, write, and speak:
List professional, trade, business or civic activities and Offices held (exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, physical disability, or other protected status information):
Please note any special courses, seminars and/or training that you have completed that would enable you to perform the position for which you are applying?
State any additional information you feel may be helpful to us in considering your application:
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References
Professional Reference:
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Personal Reference:
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
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Application Instructions
Before completing the application, check the box below to acknowledge you have read and agree to the terms provided below.
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Note: I hereby certify that the facts set forth in the above employment applications are true and complete to the best of my knowledge and authorize Community Action to verify their accuracy and to obtain reference information on my work performance. I hereby release Community Action from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. This application shall be considered 'active' for a period of time not to exceed one year. Any applicant wishing to be considered for employment beyond this time period make new application. If you are selected for an interview, we will make reasonable attempts to contact you. If you cannot be contacted, or, you are not available for the interview at the prescribed times, Community Action may not be able reschedule and you will forfeit your interview opportunity. Community Action is an Employment at Will organization. False information may render your application and any subsequent employment with this organization invalid.
Electronic Signature:
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First Name
Last Name
Date of Application:
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Month
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Day
Year
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Submit
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