First Name

Middle

Last

Address

Apartment

Other

City

State

Zip Code

Home Phone

Cell Phone

Email Address


GENERAL QUESTIONS


Are you Are you currently authorized to work in the United States without employer sponsorship? YESNO

Have you ever been convicted of a felony or a crime involving dishonesty or false statement, fraud or theft, or do you have any felony charges pending against you? YESNO
(Conviction does not constitute an automatic bar to employment). If yes, please state date, place and nature of conviction.
Nature of Conviction (if any):

Have you ever been suspended, discharged or asked to resign from employment?
YesNo

Are you able to perform all of the essential functions and duties required of the position for which you are applying, with or without reasonable accommodation?
YesNo

If no, how would you perform these essential functions and duties, and with what accommodation(s)?

Are you over 18 years old? YesNo
If no, please Select your Age and Attach your Work Permit (below):


IN CASE OF EMERGENCY, PLEASE CONTACT:

Name

What is their Relationship to you?

Relationship

Telephone

Other Phone


EMPLOYMENT HISTORY

Please list your last 3 Employers, starting with present Employer.


Most Recent Employer

Employer1

Date Started

Date Ended

Address

City & State

Telephone

Pay Rate

Position

General Duties

Supervisor's Name & Title

Reason for Leaving
DischargedResignedLaid Off


2nd Most Recent Employer

Employer2

Date Started

Date Ended

Address

City & State

Telephone

Pay Rate

Position

General Duties

Supervisor's Name & Title

Reason for Leaving
DischargedResignedLaid-Off


3rd Most Recent Employer

Employer3

Date Started

Date Ended

Address

City & State

Telephone

Pay Rate

Position

General Duties

Supervisor's Name & Title

Reason for Leaving
DischargedResignedLaid Off


EDUCATION

High School

Address

Grade of Completion

College or Trade School

Address

Grade of Completion / Degree Earned

CERTIFICATES AND/OR OTHER TRAINING


REFERENCES

Name

Phone

Title

Name

Phone

Title

Name

Phone

Title

YES I certify that all answers given are true and complete to the best of my knowledge
YES I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
YES In the event of employment, I understand that false of misleading information given in my application or interview(s) may result in discharge.


PLEASE READ THE FOLLOWING INFORMATION CAREFULLY

If I am hired and /or my employment is continued, I understand that I will be subject to immediate dismissal if any of the requested information was withheld or omitted by
me or any of the statements given by me are false, inaccurate or misleading.
I authorize investigation of all information contained in this Application and also authorize full disclosure of my present and prior work records by
any employer. I understand that this may include a record of disciplinary action accessed by the employer. I also understand that employment and/
or continued employment arising out of this Application is contingent upon the results of the investigation. I authorize Community Action of Allegan County to contact those
employers and other references I provided in this Application. I release Community Action of Allegan County and any person or prior employer from any liability arising from
or connected with disclosure of information during the investigation.

I agree that if I am hired by Community Action of Allegan County, my employment may be terminated at will at anytime for any reason or no reason at all. I further
recognize that if I am employed by the company, I will receive compensation and benefits and be subject to rules and regulations. I agree that
such compensation, benefits, rules and regulations are subject to change by the company with or without notice to me. I understand that if hired
and/or my employment is continued, I am required to comply with any and all policies of the company. I understand that any agreement altering
the terminable at-will nature of the employment relationship must be in writing and signed by me and the Executive Director of Community Action of Allegan County.
I agree to immediately notify the company if I am convicted of a felony, or any crime involving dishonesty, breach of trust, controlled substances,
abuse or violence, while my Application is pending or, if hired, during my employment.

If applying for employment in Michigan, I understand that Michigan law requires employers to make accommodation to disabled applicants and
employees where the accommodation does not impose an undue hardship on the employer. I further understand that disabled employees and
applicants must request an accommodation of their disability by notifying the company in writing of the need for accommodation with 182 days
of the date the individual knows or should know that an accommodation is needed. Failure to properly notify the company will preclude any
claim that the company failed to accommodate the disability.

Community Action of Allegan County is an equal opportunity employer. It is our policy that all applicants be considered for employment solely on the basis of qualifications
and ability, without regard to race, color, religion, national origin, sex, age, disability, veteran status, marital status or any other characteristic
protected by law unrelated to the employee's ability to perform his/her job.

I agree that any action or lawsuit against the Community Action of Allegan County and/or their employees arising out of my employment or termination of
employment, including but not limited to claims arising under state of federal civil rights statutes, must be brought within one hundred
eighty (180) days of the event giving rise to the claim or within the limitations period contained in the statute I am suing under, whichever
is shorter. I understand and agree that any action or lawsuit filed outside this limitations period is barred forever. I waive any limitation
period to the contrary.

Electronic Signature

Date

Please Attach any additional File you think is relevant such as a Cover Letter or Resume.

Should you have any problems, feel free to e-mail your resume information and position desired to:

Brenda Molendyk

email: BMolendyk@communityactionallegan.org

Phone: (269) 673-5472 ext. 234

Fax: (269) 673-3795