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Application for Employment

Mid Central Community Action, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of religion, race, national origin, sex, age, color, physical or mental disability/handicap, marital status, sexual orientation or gender identity, political affiliation, ancestry, veteran status, or any other non-merit factor.

Your Information

  • Position You're Applying for:
  • Your Name
  • Email Address
  • Address
  • Home Phone
  • Mobile Phone
  • If you don't have a phone, how can we contact you?

About You

  • When could you begin work?
  • Do you have friends, relatives or acquaintances associated with MCCA?
     Yes No
  • Are you 18 or older?
     Yes No
  • Do you have a valid driver’s license?
     Yes No
  • Driver's License Number
  • State Issued
  • Can you provide proof of insurance for your vehicle?
     Yes No

Education

  • High School
    last year completed
     9 10 11 12
  • Name of High School
  • High School City
  • High School State
  • Did you graduate?
     Yes No
  • College
    last year completed
     1 2 3 4
  • Name of College
  • College City
  • College State
  • Did you graduate?
     Yes No
  • Other School
    last year completed
     1 2 3 4
  • Name of Other School
  • Other School City
  • Other School State
  • Did you graduate?
     Yes No

Employment History

  • Previous Employment #1
  • Job Title
  • Describe your job duties
  • Name of Company
  • Address
  • State
  • Zip Code
  • Phone
  • Supervisor's Name
  • Dates worked
    From To
  • Starting Salary
  • Ending Salary
  • Reason for Leaving
  • May we contact Employer?
     Yes No
  • Previous Employment #2
  • Job Title
  • Describe your job duties
  • Name of Company
  • Address
  • State
  • Zip Code
  • Phone
  • Supervisor's Name
  • Dates worked
    From To
  • Starting Salary
  • Ending Salary
  • Reason for Leaving
  • May we contact Employer?
     Yes No
  • Previous Employment #3
  • Job Title
  • Describe your job duties
  • Name of Company
  • Address
  • State
  • Zip Code
  • Phone
  • Supervisor's Name
  • Dates worked
    From To
  • Starting Salary
  • Ending Salary
  • Reason for Leaving
  • May we contact Employer?
     Yes No
  • Previous Employment #4
  • Job Title
  • Describe your job duties
  • Name of Company
  • Address
  • State
  • Zip Code
  • Phone
  • Supervisor's Name
  • Dates worked
    From To
  • Starting Salary
  • Ending Salary
  • Reason for Leaving
  • May we contact Employer?
     Yes No
  • Please list any special training, other experience or skills which you believe should be considered in evaluating your qualifications for employment:

References

Please list three individuals with knowledge of your abilities, experience and character. (Please do not include relatives)

  • Reference #1
  • Name
  • Title
  • Place of employment
  • Address
  • Phone
  • City
  • State
  • Zip
  • Reference #2
  • Name
  • Title
  • Place of employment
  • Address
  • Phone
  • City
  • State
  • Zip
  • Reference #3
  • Name
  • Title
  • Place of employment
  • Address
  • Phone
  • City
  • State
  • Zip

Notification and Agreement

PLEASE READ BEFORE AGREEING

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT THE FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACT ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) MAY BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of MID CENTRAL COMMUNITY ACTION, INC. to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, and individuals with a disability, and any other characteristic protected by Federal, State, or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability my employer or former employers supplying such information and I also release Mid Central Community Action, Inc. from all liability that might result from making an investigation.

If hired, I agree to abide by all of MID CENTRAL COMMUNITY ACTION, INC.’S rules and regulations, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either MID CENTRAL COMMUNITY ACTION, INC. or me. I further understand that no representation, whether oral or written by any representative or agent of MID CENTRAL COMMUNITY ACTION, INC., at any time, can constitute a contract of employment. I understand that MID CENTRAL COMMUNITY ACTION, INC. and all Plan Administrators shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedure, benefits or other terms or conditions of employment. No representative or agent of MID CENTRAL COMMUNITY ACTION, INC., has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the Executive Director, or to make any agreement contrary to the foregoing.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.