Council of the Southern Mountains
148 McDowell Street
Welch, WV 24801
Phone 304-436-6800
Fax 304-436-6803
Please fill out the application below and submit to the Council at the address above. 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: Yes or No _____________________________________
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: _____________________________________________________
Thank you for your interest. CSM is an Equal Opportunity Employer.
Thank you for your interest. CSM is an Equal Opportunity Employer.