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Job Application Consent Form

Employment Application Consent Form

08/10/2022 9:36:20 AM

I , authorize North Central West Virginia Community Action Association and /or its agents to conduct independent investigation of my background, references, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of verifying the information contained on my application.

I release North Central West Virginia Community Action Association and/or its agents and any person or organization that provides information related to this authorization from any and all liabilities, claims, or lawsuits in regard to the information obtained from any of the above.

I affirm that all information on this application is correct and complete. I understand that any misstatement of facts will be grounds for the disqualification of this application. If hired, a misrepresentation will be grounds for discharge.

I have been informed that North Central West Virginia Community Action Association is an Equal Employment Opportunity Employer and does not discriminate on the basis of race, sex, age, disability, veteran status, religion, sexual orientation, color or national origin.

Nothing on this application is intended to create or imply a contractual relationship. If I am hired, I understand that employment is “at will”, is not for any specific time period, and can be terminated with or without reason at any time.

Job Applicant Email		Position Applyiing for:
Name:		County:

Do you have a Driver's license?		Are you at least 18 yrs old?
How did you hear about us?		If not 18
Primary Phone		Secondary Phone
County		Other Names that you have gone by

Have you ever filed an application with us before		Have you ever been employed with us before
Does your spouse, any of your friends or relatives or person living in your household work here		Does a member of your family serve on the Board of Directors or Head Start Policy Council of NCWVCAA
Do you have a previous criminal Conviction		Are you currently Employed
may we contact your present employer		Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status

Highest level of Education	High School
Undergraduate College	Graduate - Professional
Other Education

Previous Work Experience Employer	May we contact	Supervisor:
	Phone
Duties:	Reason
Previous Work Experience Employer	May we contact	Supervisor:
	Phone
Duties	Reason
Previous Work Experience Employer	May we contact
	Phone
Duties	Reason
Professional certifications and licenses	Professional certifications and licenses
Professional certifications and licenses


Describe any specialized training or skills
List professional business or civic activities
Other qualifications/Relevant Volunteer Activities/Comments

Personal/Professional	Name
Personal/Professional	Name
Personal/Professional	Name

Are you capable of performing with or without reasonable accommodation(s), the essential functions of the position(s) for which you are applying? A review of the activities involved in such a job or occupation has been given.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

August 9, 2022 10:21 pm EST

Job Application Consent Form Uploaded by Rob Everly - itadmin@ncwvcaa.org IP 147.0.246.114

October 5, 2022 10:23 am EST

Human Resources - hr@ncwvcaa.org added by Rob Everly - itadmin@ncwvcaa.org as a CC'd Recipient Ip: 147.0.246.114