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304.255.1397
rccoa@raleighseniors.org
1614 South Kanawha Street Beckley, WV 25801
Home
About Us
Staff
Programs & Services
Dementia & Alzheimer’s
Adult Daycare Services
In Home
Case Management
Aged and Disabled Medicaid Waiver Program
Medicaid Personal Care
Private Pay Program
Lighthouse Program
F.A.I.R. Program
Respite Program
LIFE Homemaker Program
Nutritional Services
On Site Nutrition Program
Home Delivered Meals
Social Services
Transportation
Travel Schedules
Senior Transportation Trips
Careers
Fitness & Activities
Exercise
After Hours
History Class
Computer Class
Bible Study
Genealogy Club
Building Rental and Catering
Donations
Menu
Home
About Us
Staff
Programs & Services
Dementia & Alzheimer’s
Adult Daycare Services
In Home
Case Management
Aged and Disabled Medicaid Waiver Program
Medicaid Personal Care
Private Pay Program
Lighthouse Program
F.A.I.R. Program
Respite Program
LIFE Homemaker Program
Nutritional Services
On Site Nutrition Program
Home Delivered Meals
Social Services
Transportation
Travel Schedules
Senior Transportation Trips
Careers
Fitness & Activities
Exercise
After Hours
History Class
Computer Class
Bible Study
Genealogy Club
Building Rental and Catering
Donations
Online Job Application
Position Applying For:
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Name
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First
Middle
Last
Address
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Street Address
City
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Armed Forces Americas
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Other names under which you have attended school or been employed:
Email Address:
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Phone:
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Are you eligible to work in the United States?
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Yes
No
Are you 18 years of age or older?
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Yes
No
What is your current age?
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Have you entered into an agreement with any former employer or other party that would restrict your ability to work for our company?
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Yes
No
Explain the circumstances.
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Have you ever been bonded?
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Yes
No
For which employer?
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Have you ever been employed by Raleigh County Commission on Aging?
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Yes
No
Dates of employment & reason for leaving:
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Are you related to any current RCCOA employee?
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Yes
No
Please list their name & their relationship to you:
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If required for position, do you have a valid driver’s license?
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Yes
No
State of issuance, license #, and expiration date:
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Have you ever plead “guilty” or “no contest” or been convicted of a crime?
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Yes
No
Please provide date(s) and details:
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How did you learn about this employment opportunity at Raleigh County Commission on Aging? Check all that apply:
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Ad in newspaper
Job Bulletin (Posting) /Walk-in
Website
Referral by employee
Other
Education
Name of High School:
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City/State
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Did you graduate?
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Yes
No
Number of Years Left to Graduate
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Date of Graduation
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GED
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Yes
No
City/State
Date of graduation
MM slash DD slash YYYY
Name of College:
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City/State
*
Did you graduate?
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Yes
No
Number of Years Left to Graduate
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Date of Graduation
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Degree Received
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Major
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Other School:
City / State
Did you graduate?
Yes
No
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
No
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
No
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
No
Reason for leaving?
References:
Name
First
Last
Title
Relationship to You
Phone
Email
Number of years known
Name
First
Last
Title
Relationship to You
Phone
Email
Number of years known
Name
First
Last
Title
Relationship to You
Phone
Email
Number of years known
Name
First
Last
Title
Relationship to You
Phone
Email
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:
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Date
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MM slash DD slash YYYY
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