Application for Employment

Council of the Southern Mountains

PO Box 85

Northfork WV 24868

Phone 304-862-3144

Fax 304-862-307

Application For Employment

Please fill out the application below and submit to Miranda Adams

at the Council. Thank you for your interest.

Personal Information

Date: Social Security Number:

Name:

___________

Last First Middle_______________

Present Address: ______________________

Street City State Zip Code_____________

Permanent Address: __________ __________

Street City State Zip Code____________

Phone Number:( ) _____________________

Are you related to anyone in our employ: ___________________

If yes, state name and location:

___________________________________________________________________________________________

Employment Desired

Position: Date you can start: Salary Desired: ____________________

Are you employed now? If so may we inquire to your present employer? YES or NO ___

Ever applied at this agency before? Where? When? ________ __________

Military Service Record

Branch of Service:                                                                  _________Discharge Date:                        __________
Rank:                                                                                        Present membership in National Guard or Reserves:                                                                                                  __________________________________
Date obligation ends:                                                                                                         _____________________

Education:

Name and Location of School      Graduated: YES NO            Major Subjects             Average Grades

High School:                                                                                                                    _______________________

College:                                                                                                                           _______________________

Trade Business or
Corespondence:                                                                                                             ________________________

Former Employers
(List below last four employers, beginning with present or most recent)

      Date             Name and Address of Employer                   Salary                              Position Reason for Leaving
Month and Year





                                                                                                                                       _



References
(Give the names of three persons not related to you for at least one year)

     Name & Address                              Business                     Years Acquainted____________Telephone Number__

                                                                                                                               ___________________________

                                                                                                                                ___________________________

                                                                                                                                   _________________________

                                                                                                                                ___________________________

In Case of an Emergency, Notify:

                                                                                                                                        _______________________
Name

                                                                                                                                         _______________________

Address                                                                                                              Phone Number:__________________

I authorize investigations of all statements in this application and investigation of my driving record through all department of motor vehicles. I understand that misrepresentation or omission of facts called for is cause for dismissal. Further I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any previous notice.

                                                                                                                         _______________________
Date                                                                                                                 Signature

Do not write below this line

Interviewed By:                                                _________________________________Date:________________

Remarks:
                                                                                                                                            _____________________

                                                                                                                                            _____________________

Neatness:                                               Ability:                                                                                                      ___

HireDate:                  For Dept:                 Position:                  Will Report:                           Salary/ Wages:

Council of the Southern Mountains

"Bringing Opportunities Within Reach"