Employment Form

MONTMORENCY COUNTY COMMISSION ON AGING EMPLOYMENT APPLICATION

THE MONTMORENCY COUNTY COMMISSION ON AGING IS AN EQUAL OPPORTUNITY EMPLOYER AND CONSIDERS APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, AGE, RELIGION, SEX, NATIONAL ORIGIN, DISABILITY, MARITAL STATUS, HEIGHT, WEIGHT, MILITARY SERVICE OR ANY OTHER LEGALLY PROTECTED CLASSIFICATION IN ACCORD WITH STATE AND FEDERAL LAW. THE MCCOA ALSO REASONABLY ACCOMMODATES INDIVIDUALS WITH DISABILITIES AND BONA FIDE RELIGIOUS BELIEFS. THE MCCOA IS COMMITTED TO A DRUG FREE WORKPLACE.

PLEASE PRINT AND ANSWER ALL QUESTIONS. RESUMES ARE NOT ACCEPTED IN LIEU OF COMPLETION OF THE APPLICATION. IT IS IMPORTANT TO ANSWER ALL QUESTIONS; FAILURE TO COMPLETE ALL OF THE REQUIRED INFORMATION MAY DISQUALIFY THE CANDIDATE FROM CONSIDERATION.

Applicant Information

Employment Information

Who should be contacted in the event of an emergency?

Education

(May or may not be considered depending on the job applied for).

High School

Dates are optional

College

dates are optional

Graduate

dates are optional

Other

CENA, etc.

Driving Record

(May or may not be considered depending on the position applied for)

Employment History

Please complete for all full-time or part-time employment beginning with the most recent employer. Please complete all information, failure to do so may delay the employment process.

Company 1

Beginning

Ending

Company 2

Beginning

Ending

Company 3

Beginning

Ending

References: Please list three Professional References. Please do NOT list family or friends.

Reference 1

Reference 2

Reference 3

Acknowledgement

Please read carefully and sign below

I authorize Montmorency County Commission on Aging and its agents to consult with and receive information from other companies, individuals, schools or agencies (public or private) concerning my employment, education, background, criminal or motor vehicle record, competence, experience, character or qualifications, and I authorize them to release such information to MCCOA as they request, including without limitation, my prior disciplinary record, without any obligation to give me written notice of such inquiry and/or disclosure. I also authorize MCCOA to release any information concerning my employment to any prospective or subsequent employers without any obligation to give me written notice of such disclosure. I authorize the Social Security Administration to verify that the Social Security number I will furnish is my assigned number and is valid for employment purposes. I hold harmless and release MCCOA and any individual, institution, company or agency from any liability as a result of the above inquiries and disclosures.

I understand that this Application is not an offer or a contract of employment. If I am hired by MCCOA as an employee or volunteer, I will be bound by the rules, policies, regulations, terms and conditions of employment of MCCOA as they may be communicated to me from time to time and which may be changed or modified at the will of MCCOA, in its sole discretion, with or without cause, or notice to me. I further understand and agree that MCCOA is an at-will employer which means that my employment relationship with MCCOA is for no definite period and may be terminated at any time, with or without cause, with or without notice, at the will of either MCCOA or me. I understand that the direction and control of all work is the sole prerogative of MCCOA and includes, by way of illustration only, the right to hire, layoff, transfer, reassign, demote or discharge.

I understand that according to federal law, I must produce documentation to verify my identity and authorization to work in the U.S. I agree that any employment with MCCOA is contingent on my ability to obtain and maintain the required documentation within the time period required by applicable law.

I certify that all of the information in this Application (and other information given by me in support of my application) is true and complete. I understand that any misrepresentation, misleading statement or omission of any fact by me in this Application, in support of my application for employment, or during my employment, is sufficient reason for my (1) not being offered employment or (2) being disciplined, up to and including discharge, at any time during my employment in the sole discretion of MCCOA.

I understand and agree that as a condition of employment, I may be required to undergo a post-offer medical examination, which includes a drug test. During any employment with MCCOA, I understand that I may be required to submit to an alcohol or drug screening at the request of MCCOA and I authorize the release of any such test results to appropriate personnel. I further agree that during any employment with MCCOA if I need an accommodation as the result of a disability, I will promptly notify the appropriate MCCOA representative of my need for accommodation in writing within 182 days after I learn of the need.

I agree that any claim or lawsuit relating to my application for employment, or service with Montmorency County Commission on Aging must be filed no more than six (6) months after the date of the employment action(s) or event(s) that is the subject of my claim or lawsuit. I voluntarily and knowingly waive any statute of limitations to the contrary.

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