PERSONAL:
**Position applying for:
**Second Position applying for:
**First Name:
Middle Name:
**Last Name:
**Phone: (numbers only)
Cell:
**Address:
**City:
**State:
**Zip Code: (numbers only)
**Email Address:
**Check all that you are interested in: Full Time
Part Time
Temporary
**Are You Over Age 18? Yes No
**Date Available To Start Work:

**MVCAA has facilities in the following cities. Please check all locations that would be acceptable work sites.
Brunswick   Carrollton   Higginsville
Knob Noster   Lexington   Marshall
Richmond   Salisbury   Sedalia
Warrensburg


EDUCATION:
**Did You: Graduate from High School Receive a GED Certificate

High School
**Name and Location of School:
**Academic Grade Level Completed:
**Course/Degree:

College
Name and Location of School:
Academic Grade Level Completed:
Did You Graduate? Yes No
Course/Degree:

Other School
Name and Location of School:
Academic Grade Level Completed:
Did You Graduate? Yes No
Course/Degree:


GENERAL INFORMATION:
Check computer experience: Word    Excel
PowerPoint    Database   
Email
List skills or strengths:
Are you bilingual? Yes No
If "Yes", please list language(s):
Military Service (List Branch & Dates):
If hired, can you provide written evidence that you are authorized to work in the U.S? Yes    No
List volunteer work:
Are you a current or former Head Start Parent? Yes No
**Have you ever pled guilty, or no contest to, or been convicted of a felony? Yes    No
If yes to the above question, please give dates, locations, and details:
**Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? Yes    No
If yes to the above question, please give dates, locations, and details:
**Have you ever been terminated or asked to resign from a job? Yes    No
If yes to the above question, please give details:
**Have you worked for MVCAA before? Yes    No
If yes to the above question, give dates of employment, location, program, and job title:
**Have you volunteered at MVCAA? Yes    No
If yes to the above question, please give details:
**Do you have any family members employed presently at MVCAA? Yes    No
If yes to the above question, please list name and relationship:


EMPLOYMENT EXPERIENCE:
Please list the five (5) most recent jobs. Start with the current or last job. Include armed forces services and self-employment information.

**Company Name 1:

**Address:
**Phone Number: (numbers only)
**Dates Employed: From:

   To:
**Rate of Pay (per hour or monthly): Start: Last:
**Supervisor Name:
**Job Title and Description of Work:
**Reason For Leaving:

Company Name 2:
Address:
Phone Number: (numbers only)
Dates Employed: From:

   To:
Rate of Pay (per hour or monthly): Start: Last:
Supervisor Name:
Job Title and Description of Work:
Reason For Leaving:

Company Name 3:
Address:
Phone Number: (numbers only)
Dates Employed: From:

   To:
Rate of Pay (per hour or monthly): Start: Last:
Supervisor Name:
Job Title and Description of Work:
Reason For Leaving:

Company Name 4:
Address:
Phone Number: (numbers only)
Dates Employed: From:

   To:
Rate of Pay (per hour or monthly): Start: Last:
Supervisor Name:
Job Title and Description of Work:
Reason For Leaving:

Company Name 5:
Address:
Phone Number: (numbers only)
Dates Employed: From:

   To:
Rate of Pay (per hour or monthly): Start: Last:
Supervisor Name:
Job Title and Description of Work:
Reason For Leaving:

Company Name 6:
Address:
Phone Number: (numbers only)
Dates Employed: From:

   To:
Rate of Pay (per hour or monthly): Start: Last:
Supervisor Name:
Job Title and Description of Work:
Reason For Leaving:

REFERENCES
List below the names of three persons not related to you (do not list former employers) and whom you have known for at least one year
**Name:
**Address:
**Phone Number: (numbers only)
**How long known? (140 chars max)

**Name:
**Address:
**Phone Number: (numbers only)
**How long known? (140 chars max)

**Name:
**Address:
**Phone Number: (numbers only)
**How long known? (140 chars max)




Applicant's Statement

Please read carefully before signing
I authorize investigation of all statements made on my resume, application, or those made during an interview for job selection. Such investigations may include checks for criminal record, driving record, child abuse/neglect record, drug and alcohol testing, references, and past/current employers. I authorize my former employers to furnish and release all information relating to my employment, such as the quality of work, dates of employment, and reason for leaving. In addition, I release MVCAA, any former employers and all references listed above from any and all claims, demands, or liabilities arising out of or related to such investigation or disclosure.

I understand that this application will be active for twelve (12) months; after that time, if I wish to be considered for employment, I must submit a new application. I understand that all information will be considered in determining eligibility for employment and that a false or dishonest answer to any question shall be sufficient cause for dismissal or refusal to hire. All findings related to the employment investigation will be preserved in applicant's file.

I understand that, if hired, my employment will be strictly at will. That means that my employment is for an indefinite period and that the agency or I may terminate the employment at any time, for any or no reason, with or without notice or intermediate steps. I further understand that no verbal statements or statements in any company policy or procedure manual, employee handbook, or other document shall be construed to have altered the at-will nature of my employment. No agency manager or representative shall be authorized to make any representation to the contrary.

My typed name is to be used as my electronic signature.


**Applicant Signature:
**Date: 03/23/2017



If you are a current or former employee of Department of Social Services you must read and sign the following statement in addition to the one above.
"I authorize my employer, or potential employer, to investigate, obtain, compile, examine, copy, or receive any records pertaining to my employment history; to obtain a copy of my college transcript(s); and understand completely and without reservation allow my employer to release and/or discuss any information about my employment history or college transcript(s) with authorized personnel of the Department of Social Services. I further authorize the Department of Social Services to share any personnel information that the Department of Social Services may have about me with my employer or prospective employer as the Department determines necessary to make personnel decisions regarding my suitability to provide services with my employer. By authorization of the above, the applicant agrees to hold harmless any individual, partnership, corporation, educational institution, or agency, The Department of Social Services, the Missouri Children?s Division, its officers, agents and employees, as well as the State of Missouri, from any liability for any damage whatsoever for issuing such information.

The application contains no misrepresentation or falsifications and that the information given is true and complete to the best of their knowledge and belief, that the applicant is aware that should an investigation at any time disclose any such misrepresentation or falsification as to a material fact, the application will be rejected or if selected, the applicant may be dismissed by the employer."

My typed name is to be used as my electronic signature.



**Applicant Signature:
**Date: 03/23/2017
Your Computer's IP Address: 54.147.212.173


**Required fields.
 
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Missouri Valley Community Action Agency (MVCAA) 1415 S. Odell  Marshall, MO 65340  660.886.7476
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