Employment Application | Crawford County Commission on Aging

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APPLICATION FOR EMPLOYMENT

CRAWFORD COUNTY COMMISSION ON AGING IS AN EQUAL OPPORTUNITY EMPLOYER AND DOES NOT DISCRIMINATE ON THE BASIS OF AGE, SEX, RACE, RELIGION, COLOR, NATIONAL ORIGIN, DISABILITY, MARITAL STATUS, GENETIC INFORMATION, HEIGHT, WEIGHT OR OTHER LEGALLY PROTECTED STATUS.

AUXILIARY AIDS, SERVICES, AND ALTERNATIVE FORMAT WILL BE MADE AVAILABLE UPON REQUEST TO INDIVIDUALS WITH DISABILITIES. MICHIGAN RELAY CENTER 1-800-649-3777 (VOICE AND TTY/TDD).

Employment Desired

Date of Application:*

Position Applied For*

Employment Type*

Full Time

Part Time

On-Call

If part time, specify days and hours you are available

How were you referred to the CCCOA?*

Starting salary desired:*

Date available to start*

Personal Information

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Phone*

Cell Phone*

Email address:*

Please supply any other names you have used in school or at any previous job*

Are any of your relatives employed at CCCOA?*

Yes

Please specify who works at CCCOA, and is related to you*

Ever applied to this company before?*

Yes

When did you apply?

Ever worked for this company before?*

Yes

When did you work here?*

Are you 18 years old or older?*

Yes

If not, do you have proof of eligibility to work?*

Yes

Are you Legally Authorized to work in the U.S.?*

Yes

EMPLOYMENT

Please provide all full and part-time employment history including Military Service. Start with most recent employer.

Company Name*

Phone*

Supervisor's Name*

First Last

Job Title and Responsibilities*

Start Date*

End Date (Note: If you still work there, use today's date)*

Rate of Pay:*

Reason for Leaving*

May we contact this employer for reference?*

Yes

Company Name

Phone

Supervisor's Name

First Last

Job Title and Responsibilities

Start Date

End Date

Rate of Pay:

Reason for Leaving

May we contact this employer for reference?

Yes

Company Name

Phone

Supervisor's Name

First Last

Job Title and Responsibilities

Start Date

End Date

Rate of Pay:

Reason for Leaving

May we contact this employer for reference?

Yes

Company Name

Phone

Supervisor's Name

First Last

Job Title and Responsibilities

Start Date

End Date

Rate of Pay:

Reason for Leaving

May we contact this employer for reference?

Yes

Personal References (excluding former employers or relatives)

Reference #1 Name*

First Last

Reference #1 Occupation*

Reference #1 Phone*

Reference #2 Name*

First Last

Reference #2 Occupation*

Reference #2 Phone*

Reference #3 Name*

First Last

Reference #3 Occupation*

Reference #3 Phone*

EDUCATIONAL BACKGROUND

HIGH SCHOOL

Name of School

Address

City State

Did you graduate?

Yes

Course of Study or Degree Conferred

COLLEGE

Name of School

Address

City State

Did you graduate?

Yes

Course of Study or Degree Conferred

OTHER

Name of School

Address

City State

Did you graduate?

Yes

Course of Study or Degree Conferred

OTHER

Name of School

Address

City State

Did you graduate?

Yes

Course of Study or Degree Conferred

Do you have any Special/Technical Trainings/Accreditations or Endorsements?*

Yes

Please list

What experiences, skills, or qualifications do you feel would especially qualify you for work with our organization in the position applied for?*

Do you hold any professional licenses or certifications?*

Yes

Please list and describe*

Have you ever had a professional license or certification revoked or suspended?*

Yes

Please list and describe*

Are you currently under investigation by any agency or department concerning any licensure or certification matter?*

Yes

Please describe*

Do you presently have a valid driver’s license?*

Yes

Have you had any moving violations in the past five years?*

Yes

Please provide the following information:

Date of violation*

Description of violation*

Have you been convicted of abuse or neglect of children/adults?*

Yes

Please provide the following information:

Date of charge*

Describe charge*

Have you ever been convicted of a crime, excluding routine traffic offenses?*

Yes

Please provide the following information:

Date of charge*

Describe charge*

Are there any criminal charges pending against you currently?*

Yes

Please provide the following information:

Date of charge*

Describe charge*

Do you smoke?*

Yes

Please upload a copy of your resume if you have one.

Accepted file types: pdf, Max. file size: 80 MB.

Resume must be in PDF format only.

AUTHORIZATION AND UNDERSTANDING

I represent that the answers and information given by me in this application are true and complete. I understand that any incomplete, misleading or false statements in this application or in an interview can result in immediate disqualification or termination, if hired.

I authorize CRAWFORD COUNTY COMMISSION ON AGING to verify the information I have provided and to make any investigation of my background deemed necessary both at the time of application and later, during my employment, if I am hired. I understand that the types of investigations that CRAWFORD COUNTY COMMISSION ON AGING may perform include: reference checks including personal, employment and educational reference checks and so forth. I understand that I may have to provide further information to assist in these investigations and I may be fingerprinted. I also authorize third parties (such as former employers, financial institutions, educational institutions) contacted by CRAWFORD COUNTY COMMISSION ON AGING to furnish any information relevant to my application for employment and I further release all persons and organizations from any and all liability for any and all damages whatsoever for releasing such lawful information. I also waive all written notice from all prior employers related to providing such information.

I have no objection to signing an Employee Confidentiality Statement.

In consideration of my employment, I agree to conform to the rules and policies of CRAWFORD COUNTY COMMISSION ON AGING.

This application for employment shall be considered active for the named position at time of posting only. If I wish to be considered for other openings (postings), I understand that I must submit a new application.

Authorization*

In checking this box, I hereby confirm that I have read and understood the above paragraphs, and certify all information is true and correct to the best of my knowledge.

Name

This field is for validation purposes and should be left unchanged.