HR - Coastal Georgia Area Community Action Authority Inc.

Application for Employment

We consider all applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veterans status, or any other legally protected status.

* Indicates required field

Applying For: *

Full Time Part Time Seasonal

Position(s) Applied For: *

Date *

Please read and complete all statements and questions contained in this application. Information submitted will be used to consider your qualifications and background for the position for which you apply. This application will become part of your confidential personnel record if employed. This application will be active for a period of 6 months from the date of submission.

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Other (If this is a message number please include the name of the person who resides at this residence) *

Are you legally eligible to work in the United States? *

Yes No

Are you age 18 or older? *

Yes No

How did you hear about the job opening for which you are applying? *

Newspaper Department of Labor Relative, Friend, Current Employee Other

If other, please indicate *

Have you applied for employment with the Authority in the past 6 months? *

Yes No

List relatives or friends employed by the Authority *

Have you ever been employed by the Authority? If yes, complete the following. *

Yes No

Dates employed *

Department *

Reason for termination of employment *

Position *

Supervisor *

If hired, when can you report to work? *

Do you have any future personal appointments or commitments to other employers, which may affect your being employed by the Authority? *

Yes No

If yes, explain *

What salary do you expect (approximate)? *

Some jobs may require travel, can you travel *

On daytrips for training Over night for trainings On an ongoing basis as part of the job None of the above

Do you have a current driver's license issued by the State of Georgia? *

Yes No

If you are applying for the position of Transport Driver or School Bus Driver, list all traffic violations in past 5 years which resulted in a conviction, or a guilty plea. *

If you are applying for the position of Transport Drive or School Bus Driver, list all at-fault traffic accidents in past 5 years. *

Have you ever been convicted of a crime, excluding misdemeanors? *

Yes No

Do you have any criminal charges pending at this time? *

Yes No

If you checked Yes to either of the above, please describe in full. *

Under the Head Start Program Regulation 45 CFR Part 1301, all current and prospective employees are required to declare the following. Read and mark none only if none exists. If there is a charge of conviction, notate the disposition of the arrest or charges.

All pending and prior criminal arrests and charges related to child sexual abuse and their disposition *

Yes None

If yes, notate the disposition of the arrest or charges *

Convictions related to other forms of child abuse and neglect *

Yes None

If yes, notate the disposition of the arrest or chargest *

All convictions of violent felonies *

Yes None

If yes, notate the disposition of the arrest or charges *

The above declaration may exclude traffic fines of $200 or less;

Any offense, other than, any offense related to child abuse and or child sexual abuse or violent felonies committed before the current of prospective employee's 18th birthday which was finally adjudicated in family court under a youth offender law;
Any conviction the record of which has been expunged under Federal or State law; and
Any conviction set aside under the Federal Youth Corrections Act or similar State authority.

(Applicant, please note that a conviction of a crime is not an automatic bar to employment.-All circumstances will be considered. If you are applying for a position that will require regular contact with clients served by the Authority, you will be subject to a Criminal Background Check prior to employment to the position.)

Do you have a child currently enrolled in the Head Start Program? *

Yes No

Did you or any of your family members attend a Head Start program? *

Yes No

MILITARY SERVICE

Have you ever served in the United States armed forces? *

Yes No

Branch *

Dates of Duty *

Rank at discharge *

Can you with or without reasonable accommodation, perform the essential functions of the job for which you are applying? (If you have questions about the job functions, please ask the interviewer before answering this question.) *

Yes No

EDUCATION AND SKILLS

Give a record of all High Schools, Colleges, Universities, and Special Schools you have attended.

Name of HIGH SCHOOL *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Grade Completed *

High School Diploma or GED Awarded *

Yes No

Name of COLLEGE or UNIVERSITY from which you were awarded a degree *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Major Course of Study *

Years attended *

List the Degree Awarded *

Name of COLLEGE or UNIVERSITY *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Major Course of Study *

Years attended *

Degree Awarded *

Yes No

List the Degree Awarded *

Certifications received or other Specialized Training *

SPECIAL TRAINING, SKILLS,OTHER CERTIFICATIONS, or LICENSES

(Examples: Commercial Drivers License-CDL, Child Development Associate-CDA, Certified Public Accountant-CPA, Certified in First Aide or CPR trained, etc.)

Georgia CDL Drivers License *

Yes No

Check if you can operate or do any of the following *

Explain any skills not listed above *

List software used and or any computer programs operated *

GA CDL License Expiration Date *

Endorsement *

Machinery, tools, etc. *

Certified in CPR/First Aide *

Yes No

Date this Certificate Expires *

Other *

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, religion, gender, national origin, disabilities or other protected class.

1. Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor *

Phone Number *

Type of Business *

Period of Employment (Month&Year) *

Job Duties *

Reason for Leaving *

Ending Salary *

2. Employer *

Position Held *

May we contact this employer? *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor *

Type of Business *

Phone Number *

Period of Employment (Month&Year) *

Job Duties *

Reason for Leaving *

Ending Salary *

Position Held *

May we contact this employer? *

Yes No

3. Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor *

Phone Number *

Type of Business *

Period of Employment (Month&Year) *

Job Duties *

Reason for Leaving *

Ending Salary *

Position Held *

May we contact this employer? *

Yes No

4. Employer *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Supervisor *

Phone Number *

Type of Business *

Period of Employment (Month&Day) *

Job Duties *

Reason for Leaving *

Ending Salary *

Position Held *

May we contact this employer? *

Yes No

Please explain any period of time longer than 6 consecutive months in which you were not employed. *

OTHER REFERENCES

References (Other than previous employer references above). Give the names and addresses of persons who know you (not relatives). The references given will be contacted unless we are notified by you not to contact.

1.Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship *

Years Known *

2.Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship *

Years Known *

3.Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship *

Years Known *

APPLICANTS STATEMENT

PLEASE READ VERY CAREFULLY BEFORE HITTING SUBMIT.

In making this application for employment I certify that the answers and information given herein are true and complete.

I authorize Coastal Georgia Area C.A.A., Inc. to investigate all statements contained in this application for employment as may be necessary at arriving at an employment decision. I authorize you to communicate with persons listed as references, former employers, and any others with whom you desire to check. I agree to hold such persons harmless with respect to any information they may give about me. If employed, I agree to engage in no outside activity which would involved a material conflict of interest with, or which could reflect adversely on the Authority. I understand this decision is to rest with the Authority.

If employed, I agree to hold in strictest confidence any information regarding the Authority, its clients, records, and its representatives which may come to my knowledge.

In consideration of my employment, if I am employed, I agree to conform to the employment policies of the Authority, and I understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either the Authority, or myself. I understand that no representative of the Authority, other than the Executive Director, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. I understand that completion of this Application For Employment does not guarantee that I have been employed by this Authority I hereby affirm that my answers to these statements and questions are true and correct to the best of my knowledge. I have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably. I understand that any misrepresentation, deception, or false statement made in this employment application may result in my not being considered for employment, and if not discovered by the Authority until after my becoming employed, is grounds for, and may result in, my immediate termination.

I understand that the Authority Under the Drug-free Workplace Act of 1988, Coastal Georgia Area C.A.A., Inc. requires that all applicants selected for employment pass a pre-employment drug and/or a blood alcohol test as a condition of employment, either prior to employment, or at any time during employment.

By submitting this Application for Employment, I hereby consent to either or both of said tests, at the Authority's discretion and I consent to the release of the results from any such test or examination to the Authority.

Further, I understand that the Authority requires the completion of an Initial Criminal Investigative Report prior to employment and for certain positions also requires an extensive Fingerprint Criminal Investigative Report after I am hired. By submitting this application for employment I consent to all required Criminal Investigative Reports. I realize that failure to disclose any prior arrest will be grounds for disqualification from employment.

I understand that if chosen for a position which requires driving an Authority vehicle, I will be required to submit a valid Motor Vehicles report and that as an ongoing condition of employment I must maintain a clear Motor Vehicles Report.

I realize that information received from the drug test, the initial criminal background check, the motor vehicles report may be used as a basis to disqualify me from further consideration for employment.

Submit