Step 1: Position Information

Position applying for*

Date available to start work (mm/dd/yyyy)*

Full-Time Part-Time

Number of hours available per week

Where did you learn about this position

Step 2: Personal Data

Full Name (First Middle Initial Last)*

Street Address*


City*


State*


Zip*


Daytime phone at which you can be reached*


Evening phone at which you can be reached*


Best time to contact you


What is your desired salary range?


Are you 18 years or older?
Yes No

(Only answer if applying for a Bus Driver Position) Are you 21 years or older?
Yes No

Step 3: Employment Questions

1. Have you ever applied for a job with SCCAP in the past?
Yes No
If yes, please give the date of application and the position for which you applied. State your name at that time, if different from present name.


2. Have you ever been employed by SCCAP in the past?
Yes No
If yes, please give dates of employment, position held, and your name while employed if different from present name.


3. If hired, will you be able to work during the normal days and hours required for the position(s) for which you are applying?
Yes No
If no, please explain:


4. Do you have any commitments to another employer that might affect your availability for employment with SCCAP?
Yes No
If yes, please explain:


5. Are you on a layoff and subject to recall at another employer?
Yes No

6. If hired, can you furnish proof that you are 18 years of age, or if under 18, do you have a work permit?
Yes No
If no, please explain:


7. If hired, can you furnish proof that you are eligible to work in the United States? (If unsure of the documents needed to prove eligibility to work in the United States, we will be happy to explain the legal requirements.)
Yes No
If no, please explain:


8. Do you now, or will you in the future, require SCCAP to sponsor an employment visa for your continued employment?
Yes No

9. Have you ever been convicted of a felony or misdemeanor? This does not include minor traffic violations.
Yes No
If yes, please explain: Note: a yes answer does not automatically disqualify you from employment since the nature of the offense, date, and type of job for which you are applying for will be considered.


10. Are you charged with an unresolved criminal charge (have you been charged with a crime that has not yet resulted in a plea of guilty, court trial, or dropping of the charge)?
Yes No
If yes, please explain: Note: a yes answer will not automatically disqualify you from employment.


11. Can you travel if a job requires it?
Yes No

12. Why did you apply for a position here at South Central Community Action Program, Inc.?


13. Why do you think you would make a valuable employee to South Central Community Action Program, Inc.?

Step 4: Educational Information

Additional Job-Related seminars, short courses, workshops, or other educational experiences:


Job-Related certificates, licenses, equipment qualified to operate, computer hardware and software operated, and other Job-Related special skills and abilities:


Please add any additional information (except that which identifies your race, sex, age, religion, national origin, disability or other non-job-related personal information) that you think may be relevant to a decision to hire you.


Have you ever been discharged, permitted to resign rather than be discharged, or asked to resign from any position?
Yes No
If yes, please state the employer, and the reason for the discharge or resignation.

Upload a Résumé

Select résumé/CV file from your PC:

Supported file types(.pdf, .txt, .rtf, .doc, .docx, .html)

Step 7: Authorization

PLEASE READ CAREFULLY AND INITIAL (FIRST AND LAST INITIAL) EACH PARAGRAPH BEFORE SIGNING

 By checking, I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information, misrepresentation, or material omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment by SCCAP if discovered at a later date. I agree to immediately notify SCCAP if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending or during my period of employment, if hired.

 I authorize any person, school, current employer (except as previously noted), past employers, government or investigative agencies, and other organizations that may be named in this application form (and accompanying resume, if any) to provide the company with relevant information and opinion that may be useful to SCCAP in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.

 I understand that an employer that discloses information about a current or former employee is immune from civil liability for the disclosure and the consequences proximately caused by the disclosure unless it is proven by a preponderance of the evidence that the information disclosed was known to be false at the time the disclosure was made. (Ind. Code 22-5-3-1-b)

 I authorize SCCAP to obtain the following information in connection with my application for employment, or, if hired, at any time during my employment: criminal and/or motor vehicle records, employment records, or educational records. I acknowledge that SCCAP has informed me that it may make use of this information in evaluating my application for employment, and in SCCAP decisions regarding hiring, compensation, promotion, reassignment, retention, and other terms of my employment at SCCAP. I authorize SCCAP to make use of the above-referenced information and waive any claim against SCCAP for using such information in good faith.

 I understand that if employed and my employment is terminated by SCCAP for dishonesty, breech of trust, or any criminal acts, the authorities may be notified and I may be criminally prosecuted.

 I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time.

Applicant Electronic Signature


Date (mm/dd/yyyy)