Position Applied For

Date

How did you learn about this position? How did you learn about this position? How did you learn about this position? Indeed Social Media / Facebook Friend / Relative Employee referral Craigslist Walk-in Sign posted Job Fair Worksource / Monster VCS website Other

Full Name

Street Address and/or Apartment / Unit #

City

State

Zip Code

Phone

Email

Have you ever filed an application with VCS before? Have you ever filed an application with VCS before? Yes No

Have you ever been employed with VCS before? Have you ever been employed with VCS before? Yes No

Do any of your friends or relatives work for VCS? Do any of your friends or relatives work for VCS? Yes No

If Yes, please provide name

Are you currently employed? Are you currently employed? Yes No

May we contact your present employer? May we contact your present employer? Yes No

Are you prevented from lawfully becoming employed in this country due to immigration status? (Proof of citizenship or immigration status will be required upon employment) Are you prevented from lawfully becoming employed in this country due to immigration status? (Proof of citizenship or immigration status will be required upon employment) Yes No

Date available for work

What is your desired salary range?

Are you available to work (check those that apply) Are you available to work (check those that apply) Full Time Part Time On Call / Relief Work Temporary

Please indicate preference (check those that apply) Please indicate preference (check those that apply) Mornings Afternoons Evenings Graveyard / Nights

Any other details regarding availability

Notice to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? Leave blank if you have not yet reviewed the job description. Notice to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? Leave blank if you have not yet reviewed the job description. Yes No

Do you have a High School Diploma or GED? Do you have a High School Diploma or GED? Yes No

High School Name and Location

High School Course of Study

High School Number of Years Completed

High School Diploma / Degree

Did you attend Undergraduate College? Did you attend Undergraduate College? Yes No

Undergraduate College Name and Location

Undergraduate College Course of Study

Undergraduate College Number of Years Completed

Undergraduate College Diploma / Degree

Did you attend a Graduate or Professional College? Did you attend a Graduate or Professional College? Yes No

Graduate or Professional College Name and Location

Graduate or Professional College Course of Study

Graduate or Professional College Number of Years Completed

Graduate or Professional College Diploma / Degree

Did you have other education? (please specify) Did you have other education? (please specify) Yes No

Other Education Details

WORK 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, color, religion, gender, national origin, disabilities or other protected status.) WORK 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, color, religion, gender, national origin, disabilities or other protected status.) Enter Work Experience #1

Company

Phone

Address

City, State, Zip

Job Title

From

To

Responsibilities

Reason for Leaving

Supervisor

May we contact? May we contact? Yes No

WORK EXPERIENCE WORK EXPERIENCE Enter Work Experience #2

Company

Phone

City, State, Zip

Address

Job Title

From

To

Responsibilities

Reason for Leaving

Supervisor

May we contact? May we contact? Yes No

WORK EXPERIENCE WORK EXPERIENCE Enter Work Experience #3

Company

Phone

Address

City, State, Zip

Job Title

From

To

Responsibilities

Reason for Leaving

Supervisor

May we contact? May we contact? Yes No

Describe any specialized training, apprenticeship, skills and extra-curricular activities

List professional, trade, business or civic activities and offices held

Additional Information

Personal / Professional Reference #1 Name (Do not include family members or past supervisors)

Address

Phone

Best Time to Call

Occupation

Personal / Professional Reference #2 Name

Address

Phone

Best Time to Call

Occupation

Personal / Professional Reference #3 Name

Address

Phone

Best Time to Call

Occupation

DECLARATIONS AND ACKNOWLEDGMENTS. Please check each box to confirm you read, understand, and agree to each statement. DECLARATIONS AND ACKNOWLEDGMENTS. Please check each box to confirm you read, understand, and agree to each statement. 1. I understand that the receipt of this application does not imply that I will be employed. 2. I declare that all statements and answers in this application are true and complete and agree that any untrue or misleading answer, omission concealment or failure to answer any question fully, completely and accurately will be grounds for terminating my employment, regardless of when it is discovered. 3. I authorize Village Community Services (VCS) or an agent of VCS to investigate my references, to review my former employment record and to keep and preserve records of such investigations. Additionally, I release VCS and all other parties from liability for any damage that may result from, or is related to, the furnishing of information to Village Community Services. 4. If employed, I agree to read and comply with Company rules, regulations and policies. 5. If employed, I agree that upon termination of employment, I will return all agency property and records in my possession.

Type your full name here

Date