Employment Application

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APPLICATION FOR EMPLOYMENT

Clarksville Montgomery County Community Action Agency (CMCCAA) P.O. Box 487 Clarksville, TN 37041

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a on-job-related medical condition or handicap, or any other legally protected status.
“An Equal Opportunity Employer-Program”

Application must be completed in full. Resume and other information may be attached but will not be considered in lieu of a formal Application

(PLEASE PRINT)

Date of Application *

Position Applied For: *

Referral Source *FriendRelativeEmployment AgencyWeb Search EngineAdvertisement

First Name, Middle Initial, Last Name *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Telephone

Cellphone *

Email Address *

Are you related to anyone employed by this agency or a member of the CMCCAA Head Start Policy Council, RSVP Advisory Council, or Board of Directors? *YesNo

If yes, who?

Relation

Are you a current or former Early Head Start and/or Head Start Parent? *YesNo

If necessary, best time to call you at homes is:Indicate A.M. or P.M.

Have you filed an application here before? *YesNo

If yes, give date:

Have you ever been employed here before? *YesNo

If yes, give date:

Are you employed now? *YesNo

May we contact your present employer? *YesNo

Are you authorized to work in the U.S? *Proof of citizenship or immigration status will be requested upon employment.YesNo

Salary expected: *$ per (hour, week, month, year)

On what date would you be available for work? *

Are you available to work: *Part TimeFull TimeTemporary

Are you on a lay-off and subject to recall? *YesNo

Can you travel if the job requires it? *YesNo

Have you been convicted of a felony within the last 7 years? *YesNo

If yes, please explain

If applying for a driver position:CDLChauffeurs

License #:

Endorsement(s):

Employment History

List your three(3) employers, assignments or volunteer activities, starting with the most recent including military experience.

Employer *

Dates Employed *From and To:

Telephone *

Address *

Job Title *

Hourly Rate / Salary Starting *$ per (hour, week, month, year)

Immediate Supervisor and Title *

Hourly Rate / Salary Final *$ per (hour, week, month, year)

Reason for Leaving *

Summarize the nature of the work performed and job responsibilities. *

May we contact for references? *YesNoLater

List any foreign language(s) you know or speak and check the boxes that describe your skill level.

Language

Speak SomeSpeak FluentlyReadWrite

Language

Speak SomeSpeak FluentlyReadWrite

List professional, trade, business, or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

Organization

Office(s) Held

Organization

Office(s) Held

Organization

Office(s) Held

List professional accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national origin, age, color, disability or other protected status.)

Skills and Qualifications: Summarize special skills and qualifications acquired from employment or other experiences that may qualify you to work for our agency.

Educational Background

School *

No. Years Completed *

Degree or Diploma *

GPA/Class Rank *

Major *

Minor *

List any additional information you would like us to consider or honors received thay you feel may be helpful to us in considering your application.

References: List name and telephone number of three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you.

Name

Telephone

Years Known

Name

Telephone

Years Known

Name

Telephone

Years Known

Applicant’s Statement

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that I am applying for a position that I may have unsupervised access to children less than sixteen years of age, developmentally disabled persons, or other vulnerable adults. As provided by Tennessee State Law under TCA 33-2-1201, and 71-2-111, applicants whose function would include direct contact with children or direct responsibility for persons with mental illness, serious emotional disturbance, or developmental disabilities shall agree to the release of all investigative records about the person from any source, including federal, state and local governments.

I authorize the Clarksville Montgomery Community Action Agency (CMCCAA), and its agents, or assignees, to make investigations, reference checks, security checks and other inquiries into my past regarding my application.

These queries may include, but are not limited to, the Federal Bureau of Investigation (FBI)/Tennessee Bureau of Investigation (TBI), U.S. Department of Justice, National Sex Offender Public Registry, Tennessee Abuse Registry and/or surrounding State Registries, questions pertaining to my past employment, criminal, driving and educational history, as well as, information regarding my general character and reputation.

Further, I authorize any individual, company, business entity, institution, or government agency having relevant information to furnish CMCCAA, and its agents, or assignees with that information. I agree to release and hold harmless CMCCAA from any and all liability with respect to receipt of such information and acknowledge that CMCCAA is relying on third party information and therefore release CMCCAA, its agents, and employees from any and all liability arising out of errors or omissions.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of CMCCAA.

CMCCAA is a drug-free environment. All positions are subject to periodic or random drug and alcohol tests.

Signature of Applicant

Date Signed *

Voluntary Affirmative Action Information

Applicant Name *First Name

Middle Initial

Last Name

Telephone

Cellphone *

Street Address *

City *

State/Province *

ZIP / Postal Code *

As required, we comply with government regulations including Affirmative Action obligations where they apply. In an effort comply with requirements regarding government record keeping, reporting, and other legal obligations, we ask that you complete this applicant data survey. Your cooperation is appreciated. Please be advised that your survey is not a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

Check one: *MaleFemale

Check one of the following Race/Ethnic Groups: *Hispanic or LatinoAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite

Special Notice to Vietnam Era Veterans, Desert Storm Veterans, Disabled Veterans, and Individuals with Physical or Mental Handicaps or Disabilities:
Government contractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment qualified disabled veterans and veterans of the Vietnam and Desert Storm Era, and handicapped individuals.

You are invited to volunteer this information, if you qualify, to assist in proper placement and determining reasonable accommodation. This information will be considered confidential, and refusal to provide this information will not adversely affect your consideration for employment.

If you wish to be identified, please check if any of the following are applicable:Vietnam Era VeteranDesert Storm VeteranDisabled VeteranIndividual with a Disability

To be completed by applicant—Not for interview purposes—To be filed separately from application.

This information is used to satisfy the Affirmative Action requirements of Section 503 of the Rehabilitation Acto or necessitated by another federal law or regulation.

For Human Resources Department Use Only

Position(s) Applied for:

AvailableNot Available

Other positions considered for:

HiredYesNo

Date of Hire

Position hired for:

EEO Classification:Executives/Senior level officials and managersOfficials and ManagersProfessionalsTechniciansSalesOffice and ClericalCraft Workers (skilled)Operatives (semi-skilled)LaborersService Workers

Notes:

Completed by:

Date

Save & Finish Later

We're a Community Action Agency serving Clarksville-Montgomery County, created back in 1964 to help fight poverty. We're here to support local families with everyday services and programs that make life a little easier.

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Phone: 931-896-1800
Address: 150 Lafayette Road Clarksville, TN 37042

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