Employment Application "*" indicates required fields 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 DesiredDate of Application:* MM slash DD slash YYYY Position Applied For* Employment Type* Full Time Part Time On-Call If part time, specify days and hours you are availableHow were you referred to the CCCOA?* Newspaper School Friend/Family Michigan Works Website Other Starting salary desired:*Date available to start* MM slash DD slash YYYY Personal InformationName* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 No Please specify who works at CCCOA, and is related to you*Ever applied to this company before?* Yes No When did you apply? Ever worked for this company before?* Yes No When did you work here?* Are you 18 years old or older?* Yes No If not, do you have proof of eligibility to work?* Yes No Are you Legally Authorized to work in the U.S.?* Yes No EMPLOYMENTPlease 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* MM slash DD slash YYYY End Date (Note: If you still work there, use today's date)* MM slash DD slash YYYY Rate of Pay:*Reason for Leaving*May we contact this employer for reference?* Yes No Company Name PhoneSupervisor's Name First Last Job Title and ResponsibilitiesStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay:Reason for LeavingMay we contact this employer for reference? Yes No Company Name PhoneSupervisor's Name First Last Job Title and ResponsibilitiesStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay:Reason for LeavingMay we contact this employer for reference? Yes No Company Name PhoneSupervisor's Name First Last Job Title and ResponsibilitiesStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Rate of Pay:Reason for LeavingMay we contact this employer for reference? Yes No 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 BACKGROUNDHIGH SCHOOLName of School Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Did you graduate? Yes No Course of Study or Degree Conferred COLLEGEName of School Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Did you graduate? Yes No Course of Study or Degree Conferred OTHER Name of School Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Did you graduate? Yes No Course of Study or Degree Conferred OTHER Name of School Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Did you graduate? Yes No Course of Study or Degree Conferred Do you have any Special/Technical Trainings/Accreditations or Endorsements?* Yes No Please listWhat 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 No Please list and describe*Have you ever had a professional license or certification revoked or suspended?* Yes No Please list and describe*Are you currently under investigation by any agency or department concerning any licensure or certification matter?* Yes No Please describe*Do you presently have a valid driver’s license?* Yes No Have you had any moving violations in the past five years?* Yes No Please provide the following information:Date of violation* MM slash DD slash YYYY Description of violation* Have you been convicted of abuse or neglect of children/adults?* Yes No Please provide the following information:Date of charge* MM slash DD slash YYYY Describe charge*Have you ever been convicted of a crime, excluding routine traffic offenses?* Yes No Please provide the following information:Date of charge* MM slash DD slash YYYY Describe charge*Are there any criminal charges pending against you currently?* Yes No Please provide the following information:Date of charge* MM slash DD slash YYYY Describe charge*Do you smoke?* Yes No 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 UNDERSTANDINGI 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. PhoneThis field is for validation purposes and should be left unchanged. Δ