Council of the Southern Mountains
PO Box 85
Northfork WV 24868
Phone 304-862-3144
Fax 304-862-3071
Application For Employment
Please fill out the application below and submit to Miranda Adams at the Council. Thank you for your interest.
CSM is an Equal Opportunity Employer.
Personal Information
Name:________________________________________________________________
Date: Social Security Number:________________
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 (circle one) ___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
(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: _____________________
