Job Application – Community Action of Orleans & Genesee

Step 1 of 3

Employment History

Provide employment information, including military service, for the last 15 years, starting with you most recent employer first.

Present or Last Employer

If Current Employer, may we contact them?

Name of Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Title of Position

Name and Title of Supervisor

Description of duties, responsibilities, and significant accomplishments

Reason for leaving

Next Previous Employer

Name of Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Title of Position

Name and Title of Supervisor

Description of duties, responsibilities, and significant accomplishments

Reason for leaving

Next Previous Employer

Name of Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Title of Position

Name and Title of Supervisor

Description of duties, responsibilities, and significant accomplishments

Reason for leaving

Next Previous Employer

Name of Employer

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Start Date

End Date

Title of Position

Name and Title of Supervisor

Description of duties, responsibilities, and significant accomplishments

Reason for leaving

References

List three references other than relatives

Reference 1

Name *

Occupation *

Number of Years Known *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2

Name *

Occupation *

Number of Years Known *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3

Name *

Occupation *

Number of Years Known *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Coviction Record Status

All applicants and employees must, and a condition of employment, inform the organization of all convictions. This include all convictions received within the past seven years, while you application for employment is pending, and within seven days of receiving a conviction if currently employed

Have you been convicted of, and/or plead guilty to, a felony or misdemeanor in the past seven years? *

Please Read Carefully and Sign Below

I hereby certify that all of the information I have provided on this Employment Application is true and correct to the best or my knowledge. I understand that any misreprestation or omission of facts will disqualify me from further consideration of employment, withdrawal of any offer of emplymnet, or termination of emplyment, if already hired.

I authorize verification of all of the information I have provided on this Employment Aplictaion and understand that addidtional information may be needed to consider my application for employment. I authorize all previous employers, educational institutions, references, and other persons who have knowledge of me or my records to provide any and all information pertinent to my employment and release the same from any liability resulting from providing such information. I also release this organization and all of its employees from all liability for any damage that may result from reliance on the information furnished

I understand that if employed, I am required to abide by all policies procedure, rules, and regulations of the organization. I also understand and agree that, if hired, my employment is "at-will" and is for no definite period and may, regardless of the date of payment of my wages or salary, be terminated by myself or the organization at any time with or without cause or notice.

Date *

Signature

Clear Signature

for Position of

Our Promise

Community Action changes people’s lives, embodies the spirit of hope, improves communities, and makes America a better place to live. We care about the entire community, and we are dedicated to helping people help themselves and each other.

Our Mission Statement

To provide services, with dignity and respect, that help people become self-sufficient.

We are a 501(c)3 nonprofit organization and have served low-income and disadvantaged families for nearly 60 years. Community Action programs are designed to empower as well as provide opportunity to those who are not yet self-sufficient.

This website is supported in part by Grant Number 93.569 Community Services Block Grant from the Office of Community Services and by Grant Numbers 02CH012464 and 02HP000600 from the Office of Head Start (93.600) within the Administration for Children and Families, both divisions of the U.S. Department of Health and Human Services. Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of Community Action of Orleans and Genesee, Inc. and do not necessarily reflect the views of the Administration for Children and Families and the Office of Head Start.

Personal Information

Educational Background

Employment History

References

Coviction Record Status

Please Read Carefully and Sign Below

Our Promise

Our Mission Statement