Employment Application

All new applicants are required to complete and sign this Employment Application prior to an interview.

It is the policy of CCS that all applicants for employment and all employees are recruited, hired, and assigned on the basis of merit without regard to race, color, religion, sex, sexual orientation, national origin or ancestry, age, marital or veteran status, pregnancy, or physical or mental handicap, or on any other basis prohibited by applicable laws.

Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Cell Phone or Alternate Number

Area Code Phone Number

Email

example@example.com

Birth Date

Date Date Picker Icon

Emergency Contact (Name/Relationship/Phone Number)

Health Restrictions. Note any that may apply to your ability to work at The Community Storehouse. If none, please indicate None.

Referral Source (enter name, if applicable)

Date of Application

Date Date Picker Icon

Date Available for Work

Date Date Picker Icon

Position(s) Sought

Type of Employment Desired

Full Time Part Time Temporary

Have you read the job description for which you are applying? If no, please do so before completing the remaining questions on the application.

Yes No

Have you previously applied for a position at CCS?

Yes No

Have you volunteered or been employed by a non-profit agency?

Yes No

Are you at least 18 years of age?

Yes No

Are you legally eligible for employment in the U.S. (proof will be required upon employment)?

Yes No

Are you available to work overtime and/or weekends if your position requires?

Yes No

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes No

If no, please explain.

Have you been convicted of a crime in the past 10 years that has not been annulled, expunged, or sealed by a court?

Yes No

If yes, please describe in full. (Convictions will not necessarily disqualify an applicant from employment.)

Do you have any criminal charges pending against you?

Yes No

If yes, please describe in full. (Pending charges will not necessarily disqualify an applicant from employment.)

EMPLOYMENT HISTORY:COMPLETE THE FOLLOWING INFORMATION. Start with your last/current position held, including military experience & work background.

Company

Address

Employed from Date

Date Date Picker Icon

Employed to Date

Date Date Picker Icon

Phone Number

Area Code Phone Number

Name and Title of Immediate Supervisor

May We Contact?

Yes No

Eligible for Rehire?

Yes No

Starting Base Salary

Final Base Salary

Reason for Leaving

Your Duties and Scope of Responsibility

EMPLOYMENT HISTORY

Company

Address

Employed from Date

Date Date Picker Icon

Employed to Date

Date Date Picker Icon

Phone Number

Area Code Phone Number

Name and Title of Immediate Supervisor

May We Contact?

Yes No

Eligible for Rehire?

Yes No

Starting Base Salary

Final Base Salary

Reason for Leaving

Your Duties and Scope of Responsibility

EMPLOYMENT HISTORY

Company

Address

Employed from Date

Date Date Picker Icon

Employed to Date

Date Date Picker Icon

Phone Number

Area Code Phone Number

Name and Title of Immediate Supervisor

May We Contact?

Yes No

Eligible for Rehire?

Yes No

Starting Base Salary

Final Base Salary

Reason for Leaving

Your Duties and Scope of Responsibility

EDUCATION

School Attended

Name/Location

Did You Graduate?

Yes No

Diploma, GED, or Degree?

Major

GPA

EDUCATION

School Attended

Name/Location

Did You Graduate?

Yes No

Diploma, GED, or Degree?

Major

GPA

EDUCATION

School Attended

Name/Location

Did You Graduate?

Yes No

Diploma, GED, or Degree?

Major

GPA

List special accomplishments, publications, awards.

ASSOCIATIONS:List professional, trade, business or civic associations and any offices held.

REFERENCES:Please complete the information below for three business / work references that are not related to you and are not previously listed supervisors. If not applicable, list three school / personal references that are not related to you. Providing

Name

Title

Phone (include area code)

Years Known

Reference #2

Name

Phone (include area code)

Years Known

Reference #3

Name

Phone (include area code)

Years Known

PLEASE READ BEFORE SIGNINGIf you have any questions regarding the following statements, please ask them of the Executive Director before signing this application. This application is valid for only ninety (90) days. If you have not been employed within ninety (90) days of your application, you must reapply.I certify that all of the information given by me on the application or in supplemental form is true and correct to the best of my knowledge and belief. I further understand that false or misleading statements on this application or supplemental forms are sufficient cause for my dismissal if I am hired.I understand that neither CCS’s practices or policies are to be construed as imposing any binding obligations on CCS, and that they are subject to change or deletion at any time by CCS in its sole discretion.I understand that should I be employed with CCS, I will be required, in accordance with the Immigration Reform and Control Act of 1986(IRCA), to provide on my first day of employment documents providing my identity and employment eligibility status. I acknowledge that this verification is a condition of employment and that failure to comply will void my offer of employment. I acknowledge that CCS reserves the right to require tests for alcohol or drugs during the course of my employment, consistent with applicable law, including, but not limited to the Americans with Disabilities Act. I further authorize any health care professional or testing facility who performs such an examination or who has other information concerning my test results to release such information to CCS. Drug test results with a positive outcome for any illegal substance will result in disciplinary action, up to and including termination of employment.I acknowledge and certify that I have never been suspended from participation in or subjected to any type of criminal or civil sanction, fine, civil money penalty, debarment or other penalty by any private or public health insurance program, including Medicare, Medicaid, or other federal or state health insurance program.I understand that should I be employed by CCS, my employment is “at will”. “At will” means that either party may end the relationship at any time, with or without notice. There is no promise or guarantee of employment or that my employment will continue for any specific period of time.I understand that any verbal discussions of terms or conditions of employment by CCS representatives are not binding upon CCS unless confirmed in off letters signed by the CCS Executive Director. I understand that CCS may contact past employers, educational institutions, various government databases and references for verification of the information listed in this applications, or provided by me on supplemental documents, and I authorize any such organizations or individuals to provide the requested information. I hereby acknowledge that I have read and understand each of the above statements. Provide your electronic signature by typing your name here (or parent/guardian names if under the age of 18). Include your full name. *