Western Idaho Community Action Partnership Employment Application

4. Name of Next Previous Employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Type of Business

Dates Employed

From:

To:

Reason for Leaving

Supervisor's Name & Title

List the jobs you held, duties performed, skills used or learned, advancements and promotions

CANDIDATES FOR IDAHO POSITIONS ONLY: Have you ever been convicted, entered a plea of no contest or received a withheld judgment for any criminal offense (misdemeanor or felony)? (A conviction will not necessarily disqualify an applicant.)

If yes, please explain each conviction:

Are you over 18 years of age?

Are you authorized to work in the United States? (Federal Law requires proof of identity and employment authorization for all new employees.)

For Driving Positions Only: Do you have a valid driver's license?

License Number and State Issued:

Have any of your prior employers ever disciplined you including, but not limited to, a written warning, suspension, demotion, or termination of your employment? If so, please explain each incident by providing the date, disciplinary action taken, facts surrounding the action (e.g., specific policy violation or performance issue), and the name of the employer. If you need additional space, please continue on a separate piece of paper.

Education (check last year completed)

GED/HSE

High School

School Name

College

Major Subjects

Other job-related education

If you are an experienced operator of any position-related business/plant machines or equipment or possess other job-related skills, please list:

This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, general reputation, character, and that such information may be developed through personal interviews with third parties. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons, companies,organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records. I authorize Western Idaho Community Action Partnership to release to any person, firm, entity or organization with which I may seek employment in the future,any truthful information concerning my work experience with Western Idaho Community Action Partnership. I hereby release and hold Western
Idaho Community Action Partnership harmless from any claim for releasing any truthful information within its knowledge and/or records.I understand that any job offer that may be extended to me will be contingent upon the successful completion of a drug and alcohol test. I certify that the answers given by me to the foregoing questions and during any interviews are true and correct without material omissions, and understand that, if employed, omissions and/or false statements on this application or during any interviews may result in dismissal. I understand and acknowledge that, if hired, my employment is for no definite period and either the Employer or I may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract. I have had an opportunity to have my questions about this statement's content answered and understand its terms.

Application for Employment

RECORD OF EMPLOYMENT (Use Additional Sheets if Necessary)