Chatham County Council on Aging Employment Application

Thank you for your interest in the Chatham County Council on Aging. The Council wants to find the best qualified people available to serve in its positions. Your application will be given serious consideration.

To be considered for employment with the Chatham County Council on Aging, you must answer all questions and complete all sections of this application form. The Council employs only US citizens or aliens who can provide proof of identity and work authorization within three (3) working days of employment.

In completing the application, highlight your competencies (knowledge, skills, abilities and work behaviors) that demonstrate your qualifications for the position for which you are applying. Check for accuracy, sign and date the application.

Full Name:*

First NameMiddle NameLast Name

Date:*

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Area CodePhone Number

Email:*

example@example.com

Are you at least 18 years of age?*

YesNo

Position Applied for:*

Date Available: *

Social Security No. Last 4 Digits:*

Desired Salary:*

Are you seeking:*

Shift Availability (Check all that apply):*

DayEvening

Day Availability (Check all that apply):*

Have you applied for employment with this company before?*

YesNo

Have you ever worked for this agency before?*

YesNo

If yes, give dates and position(s):

Are you related by blood, marriage, or law to anyone who works for this agency?*

YesNo

If yes, supply name:

Are you a citizen of the United States?*

YesNo

If no, are you authorized to work in the United States?

YesNo

Do you now, or will you in the future, require sponsorship for employment visa status?*

YesNo

High School:*

Address:*

From:*

To:*

Did you graduate: *

YesNo

If no, do you have your GED?

YesNo

College:

Address:

From:

To:

Did you graduate:

YesNo

Degree/Certification:

Other:

Address:

From:

To:

Did you graduate:

YesNo

Degree/Certification:

Full Name:*

Relationship:*

Phone Number:*

Email:*

Number of years known:*

Full Name:*

Relationship:*

Phone Number:*

Email:*

Number of years known:*

Full Name:*

Relationship:*

Phone Number:*

Email:*

Number of years known:*

Current/Last Employer:*

Address:*

Phone:*

Supervisor:*

Your Job Title:*

Starting Salary:*

Per Month

Ending Salary:*

Per Month

Work Performed:*

From:*

Mo/Yr

To:*

Mo/Yr

Reason for Leaving:*

May we contact this supervisor/employer for a reference? *

YesNo

Employer:

Address:

Phone:

Supervisor:

Your Job Title:

Starting Salary:

Ending Salary:

Work Performed:

From:

Mo/Yr

To:

Mo/Yr

Reason for Leaving:

May we contact this supervisor/employer for a reference?

YesNo

Employer:

Address:

Phone:

Supervisor:

Your Job Title:

Starting Salary:

Ending Salary:

Work Performed:

From:

Mo/Yr

To:

Mo/Yr

Reason for Leaving:

May we contact this supervisor/employer for a reference?

YesNo

Have you ever been convicted of (or pleaded guilty or no contest or paid a fine for any offense of any type whatsoever (this includes but is not limited to felonies, misdemeanors, DWI, hunting offenses, domestic violence, violations of city or county ordinances? This does not include minor traffic violations.*

YesNo

If yes, list all offenses, dates of convictions/pleas, county/city/state of conviction:

List all professional licenses, certifications, etc. that may be related to the position for which you are applying and list dates issued and name of organization(s) granting licenses and/or certifications.

Branch:

From:

To:

Rank at Discharge:

Type of Discharge:

If other than honorable, explain:

Check the following skills, experiences, etc. which you have:

Driver's License:

Number and State

Chauffeur's License:

Number and State

Foreign (second) Language (Specify):

Use the space below to provide whatever additional information you would like to share about your qualifications for this position or to elaborate on information already given elsewhere in this application.

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

I understand that the company will undertake, and I authorize the company to undertake, any investigation it deems necessary in considering me for employment or, if hired, my continued employment. I expressly authorize any present or former employer, school, college, university, utility company, credit or finance bureau, personal reference, chief law enforcement officer, member of any local, state, or federal law enforcement agency, or any other person to give the company any information (written or oral) or records concerning me or my qualifications, employment (including but not limited to the reason for my termination), credit, reputation, mode of living, education or criminal record. I unconditionally release the company and its representatives, agents and all persons from whom they request information from any and all liability relating to such request for information or any information provided.

I understand that this application will be active only for the specific position identified above and only during the period the company is seeking to fill the current opening(s) and that any job offer, or if hired, my continued employment, may be conditioned upon a medical examination and/or alcohol or drug testing.

I understand that, if hired, my employment will be strictly at will which means that my employment is for an indefinite period and that the company or I may terminate the employment at anytime, for any or no reason, with or without notice or intermediate steps. I further understand that no verbal statements or statements in any company policy or procedure manual, employee handbook, or other document shall be construed to have altered the at-will nature of my employment. No company manager or representative shall be authorized to make any representations to the contrary.

Signature: *

Type Full Name

Date:*

Todays Date

In order to comply with the Equal Opportunity Commission’s reporting requirements and for additional statistical purposes, the following information is being requested. This information will be kept confidential and will, in no way, be used in determining your suitability for employment with the Chatham County Council on Aging. This section is kept separate so that it will not affect the selection process.

Date of Birth (mm/dd/yyyy):*

Sex:*

MaleFemale

Ethnic Orgin:*

Who referred you to the Chatham County Council on Aging?*

Newspaper AdCouncil EmployeeEmployee Security CommissionOther

Chatham County Council on Aging Employment Application

Employment Application

Education

References

Work History

Criminal History

Professional Certifications

Military Service

Disclaimer and Signature

Equal Employment Opportunity Statistical Information ONLY