Community Action Council of Howard County, Md., Inc.
6751 Columbia Gateway Drive
Columbia, Maryland 21046
EMPLOYMENT APPLICATION
It is Community Action Council’s policy to select new employees and to promote current employees based upon
qualifications without regard to race, creed, religion, disability, color, sex, national origin, age, martial status,
political opinion or sexual orientation. Each selected applicant must meet all requirements which may include
successful completion of oral or written examination, a medical examination and a confidential background
investigation.
Position Applying For: Date of Application:
Last Name First Name Middle Name
Address City State Zip Code
Telephone Number(s): Home: _____________________ Work:____________________ Cell:_________________
E-Mail Address:
Do you possess a valid motor vehicle operator’s license? Yes No Type/Class:_________________
Have you ever been employed with us before? Yes No
If yes, give date:______________
Do any of your friends or relatives, other then spouse, work here? Yes No
If yes, state name and relationship:________________________
Are you currently employed? Yes No
May we contact your present employer? Yes No
Are you prevented from lawfully becoming employed in this country because of VISA or Yes No
Immigration Status?
Proof of citizenship or immigration status will be required upon employment
Date available to work ___/___/___ What is your desired salary range? __________
Are you available to work: Full Time Part Time Temporary
Can you travel if a job requires it? Yes No
EDUCATION AND TRAINING
School Name and address of school Course of Study No. of Years Diploma/Degree
Completed
High School
Undergraduate
College
Graduate/Professional
Other(Specify)
EMPLOYMENT HISTORY
Instructions: Please provide a complete employment history. Listing all positions held, including military, part-time, summer,
and volunteer. Use additional sheets if necessary. If submit a resume, you must complete all information except “duties”.
PRESENT OR MOST RECENT POSITION:
Employer Name: Dates Employed Duties
From ____/_____
Address:
To ____/_____
Telephone Number(s): Hourly Rate/Salary
Start $_________
Job Title: Final $_________
Name and Title of Supervisor:
Reason For Leaving:_____________________________________________________________________________
Number of Employees Supervised:____________ Types of employees supervised:_____________________
FORMER POSITION:
Employer Name: Dates Employed Duties
From ____/_____
Address:
To ____/_____
Telephone Number(s): Hourly Rate/Salary
Start $_________
Job Title: Final $_________
Name and Title of Supervisor:
Reason For Leaving:_____________________________________________________________________________
Number of Employees Supervised:____________ Types of employees supervised:_____________________
FORMER POSITION:
Employer Name: Dates Employed Duties
From ____/_____
Address:
To ____/_____
Telephone Number(s): Hourly Rate/Salary
Start $_________
Job Title: Final $_________
Name and Title of Supervisor:
Reason For Leaving:_____________________________________________________________________________
Number of Employees Supervised:____________ Types of employees supervised:_____________________
OTHER QUALIFICATIONS
Describe any specialized training, apprenticeship, skills and extra-curricular activities.
Describe any job-related training received in the United States military.
OTHER QUALIFICATIONS
Special Qualification: (Include active technical/professional licenses and academic or professional awards, etc.)
Additional Information
List below any additional information you consider pertinent to your application for employment.
GENERAL INFORMATION
Affirmative responses to the following questions will not automatically exclude you from employment consideration.
Have you ever been dismissed or asked to resign from any position for reasons other than disability? _______
If Yes, please explain:___________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________
Have you ever been convicted of an offense in an adult court?________
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were
committed, sentence(s) imposed, and type(s) of rehabilitation.:_______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PROFESSIONAL REFERENCES
Name Phone Number Best Time To Call Occupation
1.
2.
3.
The information on this application is accurate and may be verified by the Community Action Council, An Equal Opportunity Employer. I
understand and agree that any misleading or incorrect statements may render my application void and could be cause for dismissal in the
event of employment.
___________________________________________ ________________________
Signature of Applicant Date
