West Central Missouri Community Action Agency

Employment Application

Position(s) Applied for

	(first)	(middle)	(last)
Name
	(street)	(city)	(state/zip)
Address
	(home)	(work)	(message)
Telephone

Are you at least nineteen (19) years of age?	Yes No
Type of Employment Desired (check one)	Full Time Part Time Temporary
What are your salary expectations? (optional)
Auto Insurance Co.
(proof of insurance will be requested upon employment)

Has your driver’s license ever been suspended or revoked?	Yes No
Are you legally eligible for employment in this country?	Yes No
(proof of U.S. Citizenship or immigration status will be required upon employment)
Have you ever been convicted of a felony?	Yes No
Have you ever been employed here before?	Yes No

Date available for work or training
Will you travel if job requires? If no, explain.

If applying for LPN or RN position in our Health Services Division, please list the amount of professional liability insurance you carry and the company

If you are a CNA, give your certificate number, date and where it was received

Do you have a high school diploma? (check one) Yes No GED

West Central Missouri Community Action Agency is an Equal Opportunity Employer.

What was your highest grade completed in high school?

Enter information on colleges or universities attended: Name of Institution and Address, Years Attended, Majors, Total Hours, Semester Credits, Degree/Honors and Distinctions.

Volunteer or community work

List your last three employers starting with the most recent.

Employer

Address/Phone Number

Job Title/Description

Immediate Supervisor

Reason for leaving

Dates of employment & salary

Employer

Address/Phone Number

Job Title/Description

Immediate Supervisor

Reason for leaving

Dates of employment & salary

Employer

Address/Phone Number

Job Title/Description

Immediate Supervisor

Reason for leaving

Dates of employment & salary

West Central Missouri Community Action Agency is an Equal Opportunity Employer.

List special qualifications you possess that would apply to the position in which you are interested.

List three personal references (other than former employers or relatives. Include telephone number and address.

If you are handicapped and wish to be identified as such according to the Rehabilitation Act of 1973, please indicate by checking (optional)

WCMCAA FORM 24 10-98

West Central Missouri Community Action Agency is an Equal Opportunity Employer.