Community Engagement Coordinator/SDNC – Employment Application

APPLICANT INFORMATION

Name*

First Middle Initial Last

Home Phone*

Cell Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Referred by*

Are you 18 years old or older?*

Yes
No

Are you an AmeriCorps, Peace Corps, or National Service alum?*

Yes
No

Do you or any of your immediate family members conduct business with our agency? Business transactions include, but are not limited to, contracts of sale, lease, license and performance of services.*

Yes
No

If you answered "yes" above, please explain.

What is your hourly salary expectation?*

Do you have a valid driver's license?*

Yes
No

(may be a job requirement)

Are you willing to work overtime if necessary?*

Yes
No

Are you willing to work weekends?*

Yes
No

Is there anything that would prevent you from performing in a reasonable and safe manner the activities involved in the position for which you have applied?*

Yes
No

If you answered "Yes" above, please explain.

Do you have any relatives who are employed with our agency? If so, please list their name(s) here.*

(otherwise, type N/A)

Are you currently authorized to work for all employers in the United States on a full-time basis, or only for your current employer?*

All employers
Current employer only

Federal laws require the hiring of individuals who are authorized to be lawfully employed in the U.S. In compliance with such laws, FPWC will verify the status of every individual offered employment with our agency. All offers of employment are subject to verification of the applicant's identity and employment authorization, and it will be necessary for you to submit such documents as required by law to verify your identification and employment authorization.

EDUCATION

Name of High School or GED, and location:*

(for example, South High School, Garland, TX)

Did you graduate?*

Yes
No

Name of College and location:*

(for example, Univ. of Texas, Austin, TX; otherwise type N/A)

Did you graduate?*

Yes
No

Degree and fields of study:*

Please list any other licenses/certifications/training applicable to this position:

EMPLOYMENT EXPERIENCE

Are you currently employed?*

Yes
No

Employment Experience #1*

Employer

(List current employment first. If not currently employed, list the last place you worked)

*

Employer Street Address Address Line 2 City State ZIP Code

Title and responsibilities:*

This position was:*

Full time
Part time
Seasonal

Employed from/to:*

(approximate dates)

Reason for leaving:*

Supervisor name and title:*

Supervisor phone and e-mail address:*

May we contact this supervisor for a reference?*

Yes
No

Employment Experience #2*

Employer

*

Employer Street Address Address Line 2 City State ZIP Code

Title and responsibilities:*

This position was:*

Full time
Part time
Seasonal

Employed from/to:*

(approximate dates)

Reason for leaving:*

Supervisor name and title:*

Supervisor phone and e-mail address:*

May we contact this supervisor for a reference?*

Yes
No

Employment Experience #3*

Employer

Employer Street Address Address Line 2 City State ZIP Code

Title and responsibilities:

This position was:

Full time
Part time
Seasonal

Employed from/to:

(approximate dates)

Reason for leaving:

Supervisor name and title:

Supervisor phone and e-mail address:

May we contact this supervisor for a reference?

Yes
No

MILITARY SERVICE

Have you ever served in the U.S. Armed Forces? If so, list service duties, including special training relevant to the position for which you applied:

PROFESSIONAL REFERENCES

List three (3) PROFESSIONAL references:*

(include name, company, title, telephone, e-mail address, and your professional relationship with them).

DISCLAIMER AND SIGNATURE

PRE-EMPLOYMENT STATEMENT (please read very carefully before signing below): I understand and voluntarily agree that the information I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment, or if employed, termination from FPWC's employ. Any offer of employment I may receive is contingent upon my successful completion of the total pre-employment screening process, including FPWC receiving references that it considers satisfactory, and my satisfactory completion of any post offer medical examination that the agency may require. I understand that as a condition of employment, I will be required to undergo and successfully pass a screening for alcohol/drugs. I also understand and agree that, if employed, I will be required to submit to an alcohol/drug screening at any time at the discretion of FPWC. In processing my application for employment, FPWC may verify all the information provided by me, including my prior employment, military records, education, criminal and driving record. I authorize and request that all of my present/former employers and those individuals I have listed as references furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information. In consideration of my employment, I agree to comply with the policies, rules, regulations and procedures of FPWC and understand that my employment and compensation can be terminated with or without cause or notice, at any time, at the option of the either the agency or myself.

My on-line signature shall substitute for and have the same legal effect as an original form signature (type your legal name)*

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