PLEASE READ THIS APPLICATION CAREFULLY.

TRI-COUNTY COMMUNITY ACTION, INC. (TCCA)

APPLICATION FOR EMPLOYMENT

A false or dishonest answer or failure to disclose pertinent information to any question on this application will be grounds for rating ineligible for employment with TCCA, or for dismissing you after employment.  All statements on this application are subject to investigation, including checks of salaries, references, and former employers.  All information will be considered in determining your eligibility for employment with TCCA.

PLEASE READ THIS APPLICATION CAREFULLY.

 

Name:                                   

Date: 

Complete Address (include city/state/zip code): 

Phone #

==========================================================================

PERSONAL DATA:     FOR INSURANCE PURPOSES, YOU MUST BE 18 YEARS OF AGE OR OVER AND PROVIDE PROOF.

PRIOR TO EMPLOYMENT:

1)   A CRIMINAL HISTORY CHECK WILL BE COMPLETED IN ORDER TO MEET REGULATIONS.

2)  YOU MUST BE ABLE TO PROVIDE THE APPROPRIATE DOCUMENTATION REQUIRED TO VERIFY YOUR ELGIBILITY TO BE EMPLOYED IN THE U.S.

3)  YOU WILL BE REQUIRED TO PROVIDE PROOF OF CCURRENT INSURANCE COVERAGE ( LIABILITY) ON YOUR VEHICLE.  YOU MUST HAVE A VALID DRIVER'S LICENSE AND BE ABLE TO SHOW PROOF.

4)  YOUR MOTOR VEHICLE RECORD WILL BE REVIEWED AND MONITORED.  IF THE AGENCY'S INSURANCE PROVIDER DENIES COVERAGE OR CHARGES ADDITIONAL PREMIUMS, THIS MAY CAUSE DIMISSAL OF YOUR EMPLOYMENT WITH TRI-COUNTY COMMUNITY ACTION.

5)  IF CONSIDERED FOR HIRE, YOU ARE REQUIRED TO GET A PHYSICAL EXAM  CONFIRMING YOU CAN PERFORM THE FUNCTIONS OF THIS JOB WITH OR WITHOUT REASONABLE ACCOMMODATIONS.

Do you own a car?  Yes No  Do you have a valid driver's license?  Yes   No  What insurance coverage do you have on your car? 


EMPLOYMENT APPLICATION

EDUCATION:

Circle or underline the highest grade satisfactory completed:

The following information pertains to the college or university you attended (not elementary or high school):

  Name and location of College or University Major      
  1.  
  2.  
  3.  
      Dates Attended                          Years Completed                    Degree  
      From            To                                                                          Title                        Date  
 1.   
  2.  
  3.  

List any other education or special skills that are relevant to the position in which you are applying:

 

EMPLOYMENT HISTORY:  Start with your current/last employer and provide a full work history.

(1)  Name of Business 

Address (Complete) 

 

Phone # Supervisor

 

From    ToJob Title

 

Duties

 

Starting Salary                             Final Salary

                         Per Hr.WeekMonth                                                   Per Hr.WeekMonth

 

Reason for leaving: 

 

 May we contact you present employer if employed? Yes   No     If no, why not? 

 

(2)  Name of Business 

Address (Complete) 

 

Phone # Supervisor

 

From    ToJob Title

Duties

 

Starting Salary                             Final Salary

                         Per Hr.WeekMonth                                                   Per Hr.WeekMonth

 

Reason for leaving: 

 

 May we contact your present employer if employed? Yes   No     If no, why not? 

 

(3)  Name of Business 

Address (Complete) 

 

Phone # Supervisor

 

From    ToJob Title

Duties

 

Starting Salary                             Final Salary

     Per Hr.WeekMonth                                                                 Per Hr.WeekMonth

Reason for leaving: 

 May we contact your present employer if employed? Yes   No    

==========================================================================

I understand any attached forms are a part of this application and the information may be used in determining my eligibility for employment.  I authorize TCCA to inquire as to my record of any or all persons and of my former employers.  In the event of my employment to a position with TCCA, I agree to comply with the rules and regulations governing my employment.  I understand all employment with TCCA is "at will" employment.  Under "at will" employment, employment with TCCA can and may be terminated voluntarily by the employee and/ or TCCA with or without cause at any time for any reason or for no reason at all.

I understand that the first 90 days of any employment with TCCA is on a trial basis.  I understand that this application will be kept on file with Tri-County for a period of three (3) months from the date of completion.

Applicant's Signature: 

Position Applying for: 

Salary Expected:  $           per hr.      wk.       mth.  (check one)

 


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