APPLICATION FOR EMPLOYMENT

COUNCIL ON AGING, INC., serving St. Clair County

600 Grand River Ave., Port Huron, MI  48060

(810) 987-8811

______________________________________________________________________

INSTRUCTIONS:  Answer all questions.  Questions may be job-related or required by state of federal law.  It                                     depends upon the type of job for which you are applying.  Your answers will not be considered                                 unless the information is related to the job for which you are applying. THE COUNCIL ON AGING,

INC., serving St. Clair County IS A RANDOM DRUG TESTING, SMOKE-FREE ENVIRONMENT, AT WILL EMPLOYER.

____________________________________________________________________Todays Date:___________________                            

 

Position(s) Applying  For:_____    ________________________________________________________________

What kind of job do you want?   You can circle as many as you like.

 

      Full Time          Part Time        Temporary         On Call                 When can you start?__________________                         

 

Last Name:                                               First Name:                            Middle Name:________________________                                   

 

Street Address with Apt. Number:________________________________________________________________                                                                                                                   

 

City/State/Zip Code:___________________________________________________________________________                                                                                                                                         

 

Phone Number:                                                      Social Security Number:_______________________________                                                 

 

Drivers License Number:                                       State Issued In:                   Expiration Date:_______________

 

Is your license currently valid?  Yes _____  No _____  License Type(Operator/Chauffeur/CDL):____________

                                                                                                                                    Date of Birth if under

Military Service?    Yes       No       Branch of Service:                                      18 years of age:_______________                   

 

If ever employed under another name

please list name:                                             Are you lawfully employable in the United States? Yes    No_____

 

Have you ever been fired from a job?     Yes       No

If yes, explain:                                                                                ________________________________________                                                        

                                                                                                        ________________________________________                                                     

Are you able to perform the essential functions of the job to which you are applying?    Yes       No

____________________________________________________________________________________________                                                                                                                                                                         

 

Have you ever been convicted of a crime, including vehicular violations?     Yes       No

(A yes answer does not automatically disqualify you.)  If yes, explain where, when and the nature of the offense:                                                                       __________________________________________________                          

____________________________________________________________________________________________                                                                                                                                                                           

 

Do you have any relatives employed by the Council on Aging?     Yes      No

Give their names and relationship:                                                                                    _____________________                        

 

Have you ever been employed by the Council on Aging?      Yes      No

Date worked:                                            Department:                                            ___________________________                               

 

Special Skills/Certifications/Licensing:  __________________________________________________________                                                                                     ____________________________________________________________________________________________

Interests & Hobbies:                                                                                                          ______________________            ____________________________________________________________________________________________       

CoA-68 Revised 9/95; 12/00; 2/01; 12/02; 2/04;8/06; 6/09

EXPERIENCE:  Begin with your present or most recent job:                                                                       

 

Employer : ___________________________________________________________________________________                                                                                                                                     

Address, City, State:____________________________________________________________________________

Telephone #: (         )                                                 Supervisor: __________________________________________                                                                      

Dates Employed:  From:                             To:                            Hours Worked Per Week: _____________________                             

Position Held:                                                                    Number of Employees You Supervised: _______________                   

Beginning Salary:               ___          Ending Salary:        ___                     Employed:   Full Time     Part Time

Describe your job duties:                                                                                                                  _______                _   Reason for leaving:  ____________________________________________________________________________                                                                                                                                           

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Employer: ___________________________________________________________________________________                                                                                                                                       

Address, City, State:____________________________________________________________________________

Telephone #: (         )                                                 Supervisor:                                                        ______________                Dates Employed:  From:                             To:                            Hours Worked Per Week: _____________________                             

Position Held:                                                                    Number of Employees You Supervised:  _______________                 

Beginning Salary:             ___            Ending Salary:              ___               Employed:   Full Time     Part Time

Describe your job duties:  _______________________________________________________________________                                                                                                                                  

Reason for leaving: ____________________________________________________________________________                                                                                                                                           

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Employer:  __________________________________________________________________________________                                                                                                                                     

Address, City, State:___________________________________________________________________________

Telephone #: (         )                                                 Supervisor:                                                                _________        Dates Employed:  From:                             To:                            Hours Worked Per Week: ____________________                             

Position Held:                                                                    Number of Employees You Supervised: ______________                  

Beginning Salary:            ___             Ending Salary:              ___               Employed:   Full Time     Part Time

Describe your job duties: _______________________________________________________________________                                                                                                                                   

Reason for leaving: ___________________________________________________________________________                                                                                                                                            

 

EDUCATION AND TRAINING. If more space is needed, attach additional sheet and/or resume.               

 

Name of last high school attended:                                                 ______________________________________                                            

Address, City, State:____________________________________________________________________________

Did you graduate? Yes    No       Are you in high school now? Yes     No     Highest Grade Completed: ___________          

List the high school subjects you had which would help you on this job: ____________________________________                                                            

 

Name of College/University attended:                                                                                         ________________

Address, City, State:____________________________________________________________________________

Type of Degree Earned:                                         Major:                                       Minor: _______________________                                 

Number of Credits Completed:                        Semester: ________________  Quarter: _______________________

 

Name of Business/Trade/Vocational School attended:                                                  _________      __________       Address, City, State:____________________________________________________________________________

Hours per Week: __________________  Type of Degree or Certificate:____________________________________

Subjects and/or Course of Study:__________________________________________________________________                                                     

 

BUSINESS/WORK REFERENCES:

            NAME                             PHONE NUMBER                      ADDRESS                        POSITION/JOB TITLE

1.  __________________________________________________________________________________________                                                          

 

2.  __________________________________________________________________________________________                                                             

 

3.  _________________________________________________________________________________________                                                              

APPLICANT CERTIFICATION: READ CAREFULLY AND SIGN YOUR NAME.

A false answer to any question on this form may be grounds for not hiring you,  or for dismissing you after you are hired.

All answers are subject to investigation.

I certify that all statements made on this application for employment are true, complete and correct to the best of my knowledge and belief.

 

Signature:                                                                                                                          Date Signed: _______________________________________