HHWP Community Action Commission

  P.O. Box 179 · 122 Jefferson Street · Findlay, OH 45839

       Application for Employment

                                                                       

 

DATE _______________                                                   EQUAL OPPORTUNITY EMPLOYER

 

Any information on this form will be treated in a strictly confidential manner by HHWP-CAC.  Only applications that are filled out completely, signed, and received by the deadline will be considered.  The use of this form does not indicate there is any position open and does not in any way obligate this Agency.

 

LAST NAME                                                             FIRST NAME                                            MIDDLE INITIAL

 

 

CURRENT ADDRESS                                                                         CITY                         STATE                ZIP CODE

 

 

DATES IN RESIDENCE AT THIS ADDRESS

 

 

HOME PHONE                                                          CELL PHONE                        

 

 

 

 

POSITION APPLYING FOR: ____________________________________________________________

                                (NOTE - A separate application must be submitted for each position desired)

 

 

Do you have any relatives currently employed by this company?   (  )  Yes   (  )  No

Do you have any relatives currently on the Board of Directors of this company or currently on the Head Start Policy Council?    (   )  Yes    (   )  No 

 

Do you have a valid Driver’s License? (   ) Yes  (   )  No  

Driver’s License Number:  ___________________     State Issued: ________________       

Do you have adequate transportation to and from work?           (   )  Yes           (   ) No

Do you have auto liability insurance?                 (   ) Yes            (   )  No

 

Have you been convicted of or pled no contest to a crime?        Yes ______    No ______

If yes, give details: ______________________________________________________________

______________________________________________________________________________   

                                                                                                                                                           

                                                                                               

            Form #1.2.A   Rev. 09/08

EMPLOYMENT HISTORY (Begin with Last or Present Employer)  

 

EMPLOYER                                              JOB TITLE/DUTIES                              SUPERVISOR’S NAME/TITLE

 

 

ADDRESS                                                                   CITY/STATE/ZIP                    TELEPHONE NUMBER

 

DATES                                                                      SALARY/WAGE AT START:                             FINISH:

FROM:                                 TO:                             

REASON FOR LEAVING:      ___ RESIGNED WITH NOTICE    ___ QUIT (NO NOTICE)  ___ TERMINATED

IF TERMINATED, PLEASE STATE REASON: _____________________________________________________

_____________________________________________________________________________________________

MAY WE CONTACT THIS EMPLOYER:  (   ) YES   (   ) NO

 

EMPLOYER                                             JOB TITLE/DUTIES                               SUPERVISOR’S NAME/TITLE

 

 

ADDRESS                                                                   CITY/STATE/ZIP                    TELEPHONE NUMBER

 

DATES                                                                      SALARY/WAGE AT START:                             FINISH:

FROM:                                 TO:                               

REASON FOR LEAVING:      ___ RESIGNED WITH NOTICE    ___ QUIT (NO NOTICE)  ___ TERMINATED

IF TERMINATED, PLEASE STATE REASON: _____________________________________________________

_____________________________________________________________________________________________

MAY WE CONTACT THIS EMPLOYER:  (   ) YES   (   ) NO

EMPLOYER                                             JOB TITLE/DUTIES                             SUPERVISOR’S NAME/TITLE

 

 

ADDRESS                                                                   CITY/STATE/ZIP                    TELEPHONE NUMBER

 

DATES                                                                      SALARY/WAGE AT START:                             FINISH:

FROM:                                 TO:                             

REASON FOR LEAVING:      ___ RESIGNED WITH NOTICE    ___ QUIT (NO NOTICE)  ___ TERMINATED

IF TERMINATED, PLEASE STATE REASON: _____________________________________________________

_____________________________________________________________________________________________

MAY WE CONTACT THIS EMPLOYER:  (   ) YES   (   ) NO

 

Please explain fully any gaps in your employment history:                                                                                                                                                                                                                                              

List abilities and skills that may be applicable:                                                                                       

                                                                                                                                                                       

If you have applicable work experience not reflected on this application, please attach a resume.

EDUCATIONAL BACKGROUND (Complete All Sections Applicable)

NAME(S) USED WHILE ATTENDING THESE SCHOOLS:

 

HIGH

SCHOOL

 

Name of School

 

 

Course of  Study:

Address, City, State

 

 

 

 

Received Diploma?   

COLLEGE/

UNIVERSITY

 

Name

 

Major/Specialization:

 

Address, City, State

 

 

 

Type of Degree Received:

OTHER

STUDIES,

Include Military

Name

 

Course of Study:

 

 

Address, City, State

 

 

 

Type of  Certification/Licensing:

 

PROFESSIONAL REFERENCES (Other than Employers or Relatives)

 YOU HAVE KNOWN FOR AT LEAST TWO YEARS

NAME                                                                        ADDRESS                                             CONTACT NUMBER

 

1.

 

2.

 

3.

 

The information on this application is true and accurate to the best of my knowledge.  I understand that it is subject to check and that any misleading or incorrect statements may render my application void and could be cause for discharge if I am employed.  A false or dishonest answer to any questions on this application will be grounds for rating me ineligible for employment.

 

If employed, I understand and agree that my employment is “at will” and for no definite period and that my employment and compensation may be terminated at any time, at the option of either the HHWP CAC or myself, with or without cause and/or with or without any previous notice.

 

I hereby authorize the employers, schools, and personal references named in this application to provide information regarding me to the HHWP Community Action Commission.  I further authorize the release of personnel, academic and other employment records to the HHWP Community Action Commission.

 

If selected, I will be available for work on _____________________________________________________, 20_______.

 

____________________________________________________________                    ___________________________

Applicant's Signature                                                                                                                          Today’s Date

This Agency does not discriminate because of race, creed, age, sexual orientation, color, national origin, disability, or religious, union or political affiliation, in its employment and operational practices.  If you feel you have been discriminated against, contact the EEO Coordinator at (419) 423-3755.