Job Application

Position Applying For:(Required)

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

Other names under which you have attended school or been employed:

Email Address:(Required)

Phone:(Required)

Are you eligible to work in the United States?(Required)

Yes

Are you 18 years of age or older?(Required)

Yes

What is your current age?(Required)

Have you entered into an agreement with any former employer or other party that would restrict your ability to work for our company?(Required)

Yes

Explain the circumstances.(Required)

Have you ever been bonded?(Required)

Yes

For which employer?(Required)

Have you ever been employed by Raleigh County Commission on Aging?(Required)

Yes

Dates of employment & reason for leaving:(Required)

Are you related to any current RCCOA employee?(Required)

Yes

Please list their name & their relationship to you:(Required)

If required for position, do you have a valid driver’s license?(Required)

Yes

State of issuance, license #, and expiration date:(Required)

Have you ever plead “guilty” or “no contest” or been convicted of a crime?(Required)

Yes

Please provide date(s) and details:(Required)

How did you learn about this employment opportunity at Raleigh County Commission on Aging? Check all that apply:(Required)

Ad in newspaper

Job Bulletin (Posting) /Walk-in

Website

Referral by employee

Other

Education

Name of High School:(Required)

City/State(Required)

Did you graduate?(Required)

Yes

Number of Years Left to Graduate(Required)

Date of Graduation(Required)

GED(Required)

Yes

City/State

Date of graduation

Name of College:(Required)

City/State(Required)

Did you graduate?(Required)

Yes

Number of Years Left to Graduate(Required)

Date of Graduation(Required)

Degree Received(Required)

Major(Required)

Other School:

City / State

Did you graduate?

Yes

Number of Years Left to Graduate

Date of Graduation

Degree Received

Major

Skills

Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert)

WORK EXPERIENCE-Please detail your work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment, other than those due to personal illness, injury or disability. PLEASE NOTE: Raleigh County Commission on Aging, Inc. reserves the right to contact all current and former employers for reference information.

Previous Employer Name

Dates Employed (most recent position) From - to

Title

Starting Salary:

Final Salary:

Full time

Part time

Number of hours / week

Supervisor's Name, Title, and Phone Number:

Primary duties:

Other Reference Name, Title and Phone Number:

May we contact for a reference?

Yes

Reason for leaving?

Previous Employer Name

Dates Employed (most recent position) From - to

Title

Starting Salary:

Final Salary:

Full time

Part time

Number of hours / week

Supervisor's Name, Title, and Phone Number:

Primary duties:

Other Reference Name, Title and Phone Number:

May we contact for a reference?

Yes

Reason for leaving?

Previous Employer Name

Dates Employed (most recent position) From - to

Title

Starting Salary:

Final Salary:

Full time

Part time

Number of hours / week

Supervisor's Name, Title, and Phone Number:

Primary duties:

Other Reference Name, Title and Phone Number:

May we contact for a reference?

Yes

Reason for leaving?

References:

Name

First Last

Title

Relationship to You

Phone

Number of years known

Name

First Last

Title

Relationship to You

Phone

Number of years known

Name

First Last

Title

Relationship to You

Phone

Number of years known

Name

First Last

Title

Relationship to You

Phone

Number of years known

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION. I certify that the information on this application and its supporting documents is accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Raleigh County Commission on Aging, Inc. (RCCOA) to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to criminal background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment, and that an offer of employment, if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that employees of Raleigh County Commission on Aging, Inc. serve at-will, and the employment relationship may be terminated at any time by either party, or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States and that federal immigration laws require me to complete an I-9 form. I understand that this application remains current for 30 days, after that time has expired, it may be necessary for me to re-apply. I understand that this employer does not unlawfully discriminate in employment. Nor does the company tolerate harassment. I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. I certify that I have read, fully understand and accept all terms described above.

Applicant Signature:(Required)

Date(Required)

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