Employment Application

Area 10 Agency on Aging is an equal opportunity employer and will not discriminate, or tolerate discrimination, against any employee or applicant in any manner prohibited by law.

Step 1 of 7 - Applicant Information

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Are you a citizen of the United States?*
- Yes
- No
If no, are you authorized to work in the U.S.?
- Yes
- No
Have you ever worked for Area 10 Agency on Aging?*
- Yes
- No
If so, when?
Have you ever been convicted of a felony?*
- Yes
- No
If yes, explain.

High School
High School Name
High School Address
City State / Province / Region
Attended From:
MM slash DD slash YYYY
Attended To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree
College
College Name
College Address
City State / Province / Region
Attended From:
MM slash DD slash YYYY
Attended To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree
Other Education
Other Education Name
Other Education Address
City State / Province / Region
Attended From:
MM slash DD slash YYYY
Attended To:
MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree

Reference 1
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Relationship
Company
Reference 2
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Company
Reference 3
Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Company

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN.
*Area 10 Agency on Aging is an Equal Opportunity Employer and as such will recruit and hire employees without regard to race, religion, color, national origin, sex, age, political affiliation, sexual orientation, gender identity, or expression, pregnancy, or disability except when physical condition is a bona fide occupational qualification. *This application must be filled out in detail. Failure to complete all sections, or to sign this form, will result in its being returned for completion, causing delay or possible disqualification. *This application will remain active for 6 months from the date submitted. *I understand and agree that acceptance of this application in no way obligates Area 10 Agency on Aging or its partners to employ me or that there are any positions available. *As an applicant for employment with Area 10 Agency on Aging, I have furnished information for use in determining my qualifications for employment. I hereby authorize Area 10 Agency on Aging to conduct a thorough background investigation to further support the statements contained herein. *I hereby release Area 10 Agency on Aging, current and past employers and references named herein (or in accompanying resume), from liability or damage resulting from providing information requested. *If I request herein that my present employer not be contacted, an offer of employment will be conditioned upon acceptable information and verification from such employer prior to beginning work. *I agree to submit to a urine drug screen if required for the position. The results of such analysis may be grounds for disqualifying me or terminating my employment. *I agree to have a physical examination (company paid) if required for the position and understand that any offer of employment is contingent upon my passing this physical examination. *I understand and agree that if employed, I will be an employee “at will” and will have the right to terminate my employment at any time, with or without notice and with or without cause, that Area 10 Agency on Aging and its partners shall have the same right. *If employed, I agree to abide by all present and subsequently issued personnel policies and policies of employment. *I understand that if hired, I must meet the eligibility verification requirements of the Federal Immigration and Naturalization Service and submit appropriate documentation to satisfy the requirements of completing INS Form I-9. (A list of acceptable documents is available through the Human Resources department. However, the most commonly used ID is (1) a Passport or (2) a Social Security Card and Driver’s License.) *I hereby affirm that all statements made herein are true and correct to the best of my knowledge and understand that any misrepresentation may result in my being disqualified from further consideration or being terminated should I already be employed by Area 10 Agency on Aging or its partners. *My signature conveys that I have read, understand and agree to all statements listed above.
Signature

Typing your name in this field serves as your official signature for the purpose of this application.
Resume
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Resources.
Solutions.
Connections.

Employment Application

Step 1 of 7 - Applicant Information

High School

College

Other Education

Employer 1

Employer 2

Employer 3

Reference 1

Reference 2

Reference 3

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN.

Thanks to the continued support of our community partners!

Resources

Solutions

Connections

Resources. Solutions. Connections.

Employment Application

Step 1 of 7 - Applicant Information

High School

College

Other Education

Employer 1

Employer 2

Employer 3

Reference 1

Reference 2

Reference 3

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN.

Thanks to the continued support of our community partners!

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Resources

Solutions

Connections

Resources.
Solutions.
Connections.