ACCA Employment Application

Name(Required)

First Middle Last

Email(Required)

Permanent Address(Required)

Street Address City State ZIP Code

Present Address(Required)

Same as previous

Street Address City State ZIP Code

Home Phone(Required)

Work Phone

Are You 18 or older?(Required)

Yes

Who referred you for this job?(Required)

Position(s) Applied For:(Required)

Position Type(Required)

Full Time

Part Time

Temporary

Program(s) Applied For:(Required)

Have you filed an application here before?(Required)

Yes

What position(s) did you apply for, and when?(Required)

Have you ever been employed here before?(Required)

Yes

What dates were you employed here?(Required)

Under what name, if different from current name?

Education

Specific college hours must be listed in this section

Choose highest grade completed(Required)

High School Graduate or Equivalent?(Required)

Yes

Did you attend Vocational school?(Required)

Yes

Vocational School Attended(Required)

Number of Months Attended(Required)

Area of Study(Required)

Date Completed(Required)

Would you like to add college/university experience?(Required)

Yes

Colleges/Universities(Required)

Name

Major

Minor

Degree Obtained

Dates Attended

Would you like to add any professional licenses or certifications?(Required)

Yes

Licenses and Certificates(Required)

Name

Specialization

Certificate #

Expiration Date

Work History

You may not submit a resume in lieu of completing this section. Begin with your current or most recent job. You may include military and volunteer experience. If you worked for the same employer at various times and held different positions, describe each separately. Emphasize work you feel relates to the job for which you are applying.

Current or Last Employer(Required)

Address(Required)

Street Address City State

Phone(Required)

Official Job Title(Required)

Supervisor's Name(Required)

Start Date(Required)

End Date

Hours per Week(Required)

Starting Hourly Salary

Ending Hourly Salary

Reason for Leaving(Required)

May we contact employer?(Required)

Yes

Details of Duties(Required)

Would you like to enter additional work history?(Required)

Yes

This field is hidden when viewing the form

Work History 2

Employer(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Official Job Title(Required)

Supervisor's Name(Required)

Start Date(Required)

End Date(Required)

Hours per Week(Required)

Starting Hourly Salary

Ending Hourly Salary

Reason for Leaving(Required)

May we contact employer?(Required)

Yes

Details of Duties(Required)

Would you like to add additional work history?(Required)

Yes

This field is hidden when viewing the form

Work History 3

Employer(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Official Job Title(Required)

Supervisor's Name(Required)

Start Date(Required)

End Date(Required)

Hours per Week(Required)

Starting Hourly Salary

Ending Hourly Salary

Reason for Leaving(Required)

May we contact employer?(Required)

Yes

Details of Duties(Required)

Special Questions

Do you have access to a personal car for use on the job?(Required)

Yes

Auto Insurance Information(Required)

Insurance Carrier/Company

Policy Number

Driver Information(Required)

Drivers License Number

Class

Exp Date

Have you had any moving violations in the last three years?(Required)

Yes

Please list the date and description of each moving violation you have had in the last three years.(Required)

Date

Violation

Have you ever been convicted of a felony?(Required)

Yes

Have you ever been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable source) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct?(Required)

Yes

What is your COVID-19 vaccination status?(Required)

I am fully vaccinated.

I am not fully vaccinated.

Documentation of vaccination will be requested upon hire.

If you are not fully vaccinated, which statement best applies to you?(Required)

I am willing to get fully vaccinated against COVID-19.

I am not planning to get vaccinated against COVID-19.

Special Skills and Qualifications(Required)

List any additional training or experience that might qualify you for this position. Please include volunteer experience and computer skills.

Professional References(Required)

Full Name

Business

Years Known

Phone Number

Give the names of three persons not related to you, whom you have known at least one year.

Agreement

I certify that answers given herein are true and complete to the best of my knowledge and understand that, if employed, false or misleading statements on this application or interview(s) may result in discharge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I consent to all medical examinations required both as a condition of employment and continuing employment. Should I be accepted for employment I will fully adhere to the rules and regulations of employment at the Athens Community Council on Aging. Upon termination of employment I authorize the release of reference information of my work for the Athens Community Council on Aging. I hereby certify that all entries on this job application and any attachments are true and complete. I also agree and understand that any falsification this information may result in my forfeiture of employment. I understand that all information on this job application is subject to verification and I consent to criminal history and background checks. I also agree that you may contact references and educational institutions listed on this application

Signature(Required)

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